PENGKAJIAN KEPERAWATAN

KESEHATAN JIWA

Tanggal MRS :
Tanggal Dirawat di Ruangan :
Tanggal Pengkajian :
Ruang Rawat :

I. IDENTITAS KLIEN
Nama : John Forbes Nash
Umur :
Alamat : Amerika Serikat
Pendidikan : S3
Agama : Kristen
Status : Menikah
Pekerjaan : Matematikawan
Jenis Kelamin : Laki-laki
No CM :

II. ALASAN MASUK

a. Data Primer
Klien merupakan orang yang suka menyendiri, rendah hati, dan introvert. Klien
mengatakan bahwa ia tidak terlalu suka berhubungan dengan orang lain. Menurut ia
tidak ada orang yang menyukai dirinya
b. Data Sekunder
Istri klien mengatakan bahwa sifat klien terlihat semakin aneh semenjak usai menikah
dan terlihat sangat ketakutan. Istri klien akhirnya mencari tahu tentang teman
sekamar klien ketika kuliah dulu, ternyata sosok teman yang selama ini diceritakan
oleh suaminya tidak ada, klien hanya tinggal sendiri di asrama tersebut.

c. Keluhan Utama Saat Pengkajian

Klien mengalami halusinasi dimana ia memiliki teman khayalan.

III. RIWAYAT PENYAKIT SEKARANG (FAKTOR PRESIPITASI)

Setelah diberikan tugas untuk memecahkan kode rahasia klien mulai merasa ketakutan
dalam menjalani hidupnya. Ketika memberikan materi saat kuliah tamu, klien mencoba
melarikan diri karena melihat orang-orang yang menurutnya agen misterius yang ingin
menangkapnya. Klien meninju orang tersebut untuk melawan, sehingga klien diberikan
suntikan bius dan dibawa ke rumah sakit jiwa. Klien diberikan terapi kejut insulin dan
kemudian dilepaskan. Klien menjadi lesu dan tidak responsif akibat dari efek samping
obat antipsikotik tersebut yang diminum oleh klien. Karena itulah klien diam-diam
 berhenti meminum obat tersebut. Hal ini menyebabkan halusinasi klien kambuh lagi dan
menurutnya ia bertemu dengan teman khayalannya.

IV. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)

1. Pernah mengalami gangguan jiwa di masa lalu ?
 Ya
 Tidak
Jika Ya,Jelaskan kapan, tanda gejala/keluhan :

Semasa kuliah klien sudah mengalami halusinasi. Klien menganggap bahwa ia

memiliki teman sekamar, padahal ia hanya tinggal sendirian di asrama tersebut.
2. Faktor Penyebab/Pendukung
a. Riwayat Trauma
Usia Pelaku Korban Saksi
1. Aniaya fisik ………… ………… ………… …………
2. Aniaya seksual ………… ………… ………… …………
3. Penolakan ………… ………… ………… …………
4. Kekerasan dalam keluarga ………… ………… ………… …………
5. Tindakan kriminal ………… ………… ………… …………

Sebelum mendapatkan perawatan klien pernah memukul temannya karena merasa

dapat membahayakan dirinya.
b. Pernah melakukan upaya / percobaan / bunuh
diri Jelaskan:
Tidak pernah
DiagnosaKeperawatan : -

c. Pengalaman masa lalu yang tidak menyenangkan (peristiwa kegagalan,

kematian, perpisahan)
Jika ada jelaskan :
Klien mengalami frustasi ketika ia tidak dapat menemukan ide yang muncul dari
dirinya sendiri untuk mendapatkan gelar doktorny. Sedangkan temannya sudah
berhasil menerbitkannya. Klien merasa tertekan sehingga suka menyendiri.

DiagnosaKeperawatan : Isolasi sosial

d. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
 Ya
 Tidak

e. Riwayat Penggunaan NAPZA

Klien tidak memiliki riwayat penggunaan NAPZA
Diagnosa Keperawatan : -
3. Upaya yang telah dilakukan terkait kondisi di atas dan hasilnya :

Ketika frustasi karena tidak kunjung menemukan ide, klien membenturkan kepalanya
ke kaca jendela kamar hingga keningnya berdarah. Namun teman khayalannya
mencoba untuk menghentikannya agar tidak melakukan hal yang lebih membahayakan
lagi. Akhirnya klien bisa tenang. Sampai akhirnya ia melihat seorang gadis yang
membuatnya terpikirkan konsep baru yang bertentangan dengan teori Adam Smith.
Dari sinilah ia akhirnya menemukan ide yang mengantarkannya berhasil meraih gelar
doktor dan impiannya untuk diterima di pusat penelitian bergengsi terwujud.
4. Riwayat Penyakit Keluarga
Anggotakeluarga yang gangguanjiwa ?
 Ada
 Tidak
Jika ada :
Hubungankeluarga :
Gejala :
Riwayat pengobatan :
Diagnosa Keperawatan :
V. PENGKAJIAN PSIKOSOSIAL (Sebelum dan sesudah sakit)
1. Genogram:

Jelaskan:
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Diagnosa Keperawatan :
2. Konsep Diri a.
Citra tubuh :
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 b. Identitas :
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c. Peran :
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d. Ideal diri :
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e. Hargadiri :
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Diagnosa Keperawatan :
3. Hubungan Sosial
a. Orang yang berarti/terdekat
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b. Peran serta dalam kegiatan kelompok/masyarakat dan hubungan sosial
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c. Hambatandalamberhubungandengan orang lain
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Diagnosa Keperawatan :

4. Spiritual
a. Agama
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b. Pandangan terhadap gangguan jiwa
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Diagnosa Keperawatan:

VI. PEMERIKSAAAN FISIK

1. Keadaan umum
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2. Kesadaran (Kuantitas)
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3. Tanda vital:
TD : ……. mm/Hg
N :…….. x/menit
O
S : …….. C
P : …….. x/menit
4. Ukur:
BB : ……. Kg

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 TB : ……. Cm
5. Keluhan fisik:
Jelaskan :
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Diagnosa Keperawatan :
VII. STATUS MENTAL
1. Penampilan (Penanpilan usia, cara perpakaian, kebersihan)
Jelaskan:
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Diagnosa Keperawatan:
2. Pembicaraan (Frekuensi, Volume, Jumlah, Karakter) :
Jelaskan:
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Diagnosa Keperawatan:
3. Aktifitasmotorik/Psikomotor
Kelambatan :
 Hipokinesia,hipoaktifitas
 Katalepsi
 Sub stupor katatonik
 Fleksibilitas serea
Jelaskan:
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Peningkatan :

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 Hiperkinesia,hiperaktifitas Grimace

Stereotipi Otomatisma

Gaduh Gelisah Katatonik Negativisme

Mannarism Reaksikonversi

Katapleksi Tremor

Tik Verbigerasi

Ekhopraxia Berjalankaku/rigid

Command automatism Kompulsif :sebutkan …………

Jelaskan:
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Diagnosa Keperawatan :
4. Mood dan Afek
a. Mood
Depresi Khawatir

Ketakutan Anhedonia

Euforia Kesepian

Lain

lainJelask
an
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b. Afek
Sesuai Tidak sesuai
Tumpul/dangkal/datar Labil

Jelaskan:
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Diagnosa Keperawatan

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5. Interaksi Selama Wawancara
Bermusuhan Kontak mata kurang
Tidak kooperatif Defensif

Mudah tersinggung Curiga

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6. Persepsi Sensorik
a. Halusinasi
 Pendengaran
 Penglihatan
 Perabaan
 Pengecapan
 Penciuman
b. Ilusi
 Ada
 Tidakada
Jelaskan:
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Diagnosa Keperawatan
7. Proses Pikir
a. ArusPikir:
Koheren Inkoheren

Sirkumtansial Asosiai longgar

tangensial Flight of Idea
Blocking Perseverasi

Logorhoe Neologisme

Clang Association Main kata kata

Afasia Lain lain…
Jelaskan:
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b. Isi Pikir
Obsesif Fobia,sebutkan…………..

Ekstasi Waham:

Fantasi o Agama
Alienasi o Somatik/hipokondria
Pikiran bunuh diri o Kebesaran
Preokupasi o Kejar / curiga
Pikiran isolasisosial o Nihilistik
Ide yang terkait o Dosa
PikiranRendahdiri o Sisip pikir
Pesimisme o Siar piker
Pikiran magis o Kontrol pikir

Pikiran curiga Lain lain :

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c. Bentuk pikir :
 Realistik
 Non realistik
 Dereistik
 Otistik
Jelaskan:
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Diagnosa Keperawatan:

8. Kesadaran

Orientasi (waktu, tempat,
orang) Jelaskan:
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 Meninggi
 Menurun:

 Kesadaran berubah
 Hipnosa
 Confusion
 Sedasi
 Stupor
Jelaskan:
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Diagnosa Keperawatan:
9. Memori
 Gangguan daya ingat jangka panjang ( > 1 bulan)
 Gangguan dayaingat jangka menengah ( 24 jam - ≤ 1 bulan)
 Gangguan daya ingat pendek (kurun waktu 10 detik sampai 15 menit)
Jelaskan:
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Diagnosa Keperawatan:
10. Tingkat Konsentrasi dan
Berhitung a. Konsentrasi
 Mudah beralih
 Tidak mampu berkonsentrasi
Jelaskan:
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b. Berhitung
Jelaskan:
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 Diagnosa Keperawatan:
11. Kemampuan Penilaian
 Gangguan ringan
 Gangguan bermakna
Jelaskan :
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Diagnosa Keperawatan:
12. Daya Tilik Diri
 Mengingkari penyakit yang diderita
 Menyalah kanhal-hal diluar dirinya
Jelaskan:
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Diagnosa Keperawatan:

VIII. KEBUTUHAN PERSIAPAN PULANG

1. Kemampuan klien memenuhi kebutuhan
 perawatan kesehatan,

 transportasi,
 tempat tinggal.
 Keuangan dan kebutuhan
lainnya. Jelaskan:
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2. Kegiatan Hidup Sehari hari
a. Perawatan diri
1) Mandi
Jelaskan :
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 2) Berpakaian, berhias dan berdandan
Jelaskan :
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3) Makan
Jelaskan :
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4) Toileting (BAK, BAB)
Jelaskan :
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Diagnosa Keperawatan:
b. Nutrisi
Berapa frekwensi makan dan frekwensi kudapan dalam sehari.
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Bagaimana nafsu makannya
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Bagaimana berat badannya.
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Diagnosa Keperawatan:
c. Tidur
1) Istirahat dan tidur
Tidur siang, lama : ____________ s/d _____________
Tidur malam, lama : _____________ s/d _____________
Aktifitas sebelum/sesudah tidur : __________ , _________
Jelaskan
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 2) Gangguan tidur
 Insomnia
 Hipersomnia
 Parasomnia

 Lain lain

Jelaskan
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Diagnosa Keperawatan:

3. Kemampuan lain lain

Mengantisipasi kebutuhan hidup

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 Membuat keputusan berdasarkan keinginannya,
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 Mengatur penggunaan obat dan melakukan pemeriksaan kesehatannya sendiri.
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Diagnosa Keperawatan:
4. Sistem Pendukung Ya Tidak
Keluarga
Terapis
Teman sejawat
Kelompok sosial
Jelaskan :
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Diagnosa Keperawatan:

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IX. MEKANISME KOPING
Jelaskan :
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Diagnosa Keperawatan:

X. MASALAH PSIKOSOSIALDAN LINGKUNGAN

 Masalah dengan dukungan kelompok, spesifiknya
Jelaskan :
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 Masalah berhubungan dengan lingkungan, spesifiknya
Jelaskan :
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 Masalah dengan pendidikan, spesifiknya
Jelaskan :
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 Masalah dengan pekerjaan, spesifiknya
Jelaskan :
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 Masalah dengan perumahan,
spesifiknya Jelaskan :
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 Masalah dengan ekonomi, spesifiknya
Jelaskan :
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 Masalah dengan pelayanan kesehatan, spesifiknya
Jelaskan :
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 Masalah lainnya, spesifiknya
Jelaskan :
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Diagnosa Keperawatan:

XI. ASPEK PENGETAHUAN

Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang kurang
tentang suatu hal?
Bagaimana pengetahuan klien/keluarga saat ini tentang penyakit / gangguan jiwa,
perawatan dan penatalaksanaanya faktor yang memperberat masalah (presipitasi), obat-
obatan atau lainnya. Apakah perlu diberikan tambahan pengetahuan yang berkaitan
dengan spesifiknya masalah tsb
Penyakit/gangguan jiwa Penatalaksanaan

Sistem pendukung Lain-lain, jelaskan

 Faktor
presipitasi Jelaskan :
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 Diagnosa Keperawatan:

XII. ASPEK MEDIS

1. Diagnosis Multi Axis
Axis I : .........................................................................................................................
Axis II : ........................................................................................................................
Axis III : .........................................................................................................................
Axis IV : .........................................................................................................................
Axis V : ........................................................................................................................
2. Terapi Medis
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XIII. ANALISA DATA

DIAGNOSA
NO DATA
KEPERAWATAN
1. DS:
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DO:
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2. DS:
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DO:
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3. DS:
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DO:
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4. DS:
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DO:
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dst DS:
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DO:
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XIV. DAFTAR DIAGNOSA KEPERAWATAN
1. ………………………………………
2. ………………………………………
3. ………………………………………
4. ………………………………………
5. ………………………………………
6. ………………………………………
7. ………………………………………
8. dst

XV. POHON MASALAH

XVI. PRIORITAS DIAGNOSA KEPERAWATAN

1. ……………………………………………….
2. ………………………………………………
3. ………………………………………………
4. .………………………………………………

Lawang, ……………………….
Perawat yang mengkaji

____________________
NIM/NIRM: ..………….

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 TINDAKAN KEPERAWATAN JIWA
Nama : Ruang :
No CM : Unit :
Tanggal Diagnosa
No Tindakan Keperawatan Evaluasi Ttd
Jam Keperawatan

1
Keterangan :
Cara pendoku mentasian :
 Mengacu pada fasefase komunikasi terapeutik
 Pada kolom waktu diisi : Dx. Kep, Tanggal & jam tindakan
 Pada kolom Tindakan Keperawatan diisi :
 Fase Oreantasi : Saat evaluasi/ validasi
 Fasekerja : Sesuai tindakan fase kerja
 Fase terminasi : Rencana Tindak Lanjut
 KolomEvaluasi:
 Evaluasi subyektif & Obyektif
 Berdasarkan respon subyektif, evaluasi obyektif
 Sesuai hasil evaluasi respon subyektif & obyektif pada fase terminasi
 A : Analisa , Sesuai dengan hasilin teraksi terakhir
 P : Planning , terdiridari P pasien dan P perawat
 P pasien : berdasarkan hasil rencana tindak lanjut pada fase terminasi
 P perawat : berdasarkan hasil kontrak yang akan datang pada fase
terminasi