PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

I. IDENTITAS KLIEN :
1. Nama 8. Status
2. No. Register 9. Alamat
3. Umur
4. Suku 10. Tgl Masuk
5. Agama 11.Tgl Pengkajian
6.Jenis Kelamin 12. Informan
7. Pendidikan 13. Dx Medis

II. ALASAN MASUK RUMAH SAKIT

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III. FAKTOR PREDISPOSISI

1. Pernah mengalami gangguan jiwa dimasa lalu?
□ Ya □ Tidak
Jika ya, jelaskan............................................................................................................
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2. Pengobatan sebelumnya?
□ Berhasil □ Kurangberhasil □ Tidakberhasil
3. Pengalaman Pelaku/Usia Korban/Usia Saksi/Usia
Aniaya fisik
Aniaya seksual
Penolakan
Kekerasandlm. Keluarga
Tindakan kriminal

Jelaskan
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Masalah keperawatan....................................................................................................

4. Adakahanggota keluarga yang mengalami gangguan jiwa?

□ Ya □ Tidak
Hubungan keluarga Gejala Riwayat Pengobatan /Perawatan
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Masalah keperawatan ...................................................................................................

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 5. Pengalamanmasa lalu yang tidak menyenangkan
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Masalah keperawatan ...................................................................................................

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IV. FISIK
1. Keadaan Umum: .........................................................................................................
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2. Tanda vital TD = .................N = .................S = .................P = .................
3. Ukur TB = .................BB = .................
4. Keluhan fisik
□ Ya □ Tidak
Jelaskan.........................................................................................................................
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Masalah keperawatan............................................................................................
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V. PSIKOSOSIAL
1. Genogram :

Jelaskan .....................................................................................................................
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Masalah keperawatan ...............................................................................................

2. Konsep diri:
a. Gambaran diri :....................................................................................................
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b. Identitas : .................................................................................................................
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c. Peran : .....................................................................................................................
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d. Ideal diri : .................................................................................................................

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e. Harga diri : ..............................................................................................................

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Masalah keperawatan .........................................................................................

3. Hubungan sosial:
a. Orang yang berarti: .............................................................................................
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b. Peran serta dalam kegiatan kelompok / masyarakat : ........................................

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c. Hambatan dalam berhubungan dengan orang lain : ...........................................

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 d. Spiritual :
a. Nilai dan keyakinan : ..........................................................................................
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b. Kegiatan ibadah : ...............................................................................................

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Masalah keperawatan ..........................................................................................

VI. STATUS MENTAL :

1. Penampilan :
□ Tidak rapi □ Penggunaan pakaian tak □ Cara berpakaian tidak
sesuai seperti biasanya
Jelaskan: ...............................................................................................................
Masalah keperawatan : ..............................................................................................

2. Pembicaraan:
□ Cepat □ Keras □ Gagap □ Inkoheren
□ Apatis □ Lambat □ Membisu □ Tidakmampumemulaipembicaraan
Jelaskan ................................................................................................................
Masalah keperawatan ................................................................................................

3. Aktivitas motorik :
□ Lesu □ Tegang □ Gelisah □ Agitasi
□ Tik □ Grimasing □ Tremor □ Kompulsif
Jelaskan :..................................................................................................................
Masalah keperawatan :...............................................................................................

4. Alamperasaan :
□ Sedih □ Ketakutan □ Putus □ Khawatir □ GembiraBerlebihan
Asa
Jelaskan :………........................................................................................................
Masalah keperawatan :...............................................................................................

5. Afek:
□ Datar □ Tumpul □ Labil □ Tidak sesuai
Jelaskan:.....................................................................................................................
Masalah Keperawatan :…..........................................................................................

6. Interaksi Selama Wawancara :

□ Datar □ Tumpul □ Labil □ Tidak sesuai
Jelaskan : ...................................................................................................................
Masalah keperawatan : ..............................................................................................
7. Persepsi :
Halusinasi.
□ Pendengaran □ Penglihatan □ Perabaan
□ Pengecapan □ Pembauan/penciuman
Jelaskan :....................................................................................................................
Masalah keperawatan : ..............................................................................................

8. Proses Pikir :
□ Sirkumstansial □ Tangensial □ Gg. Asosiasi
□ Flight of ideas □ Blocking □ Perseverasi / pengulangan
pembicaraan
Jelaskan : ...................................................................................................................
Masalah keperawartan : .............................................................................................

9. Isi pikir :
□ Obsesi □ Fobia □ Hypocondria
□ Depersonalisasi □ Ide yang terkait □ Pikiran mistik
Waham :
□ Agama □ Somatik □ Kebesaran □ Curiga
□ Nihilistik □ Sisippikir □ SiarPikir □ KontrolPikir
Jelaskan : ..................................................................................................................
Masalah keperawatan : ..............................................................................................

10. Tingkat kesadaran.

□ Bingung □ Sedasi □ Stupor
Disorientasi :
□ Waktu □ Tempat □ Orang
Jelaskan : .................................................................................................................
Masalah keperawatan : .............................................................................................

11. Memori.
□ Gg. daya ingat jangka panjang □ Gg daya ingat jangka pendek
□ Gg. Daya ingat saat ini □ Konfabulasi
Jelaskan : ..................................................................................................................
Masalah keperawatan : .............................................................................................

12. Tingkat konsentrasi dan berhitung.

□ Mudah beralih □ Tidakmampu □ Tidakmampuberhitungsederhana
berkonsentrasi
Jelaskan : ..................................................................................................................
Masalah keperawatan : .............................................................................................
 13. Kemampuan penilaian
□ Gangguanringan □ Gangguanbermakna
Jelaskan : ..................................................................................................................
Masalah keperawatan : .............................................................................................

14. Daya tilik diri.

□ Mengingkari penyakitnya □ Menyalahkan hal - hal diluar
dirinya
Jelaskan : ...................................................................................................................
Masalah keperawatan : ..............................................................................................

VII. KEBUTUHAN PERSIAPAN PULANG .

1. Makan
 Bantuan Minimal
 Bantuan total
Jelaskan:…………………………………………………………………………………………
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2. BAB/BAK
 Bantuan minimal
 Bantuan total
Jelaskan:…………………………………………………………………………………………
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3. Mandi
 Bantuan minimal
 Bantuan total
Jelaskan:…………………………………………………………………………………………
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4. Berpakaian/berhias
 Bantuan Minimal
 Bantuan total
Jelaskan:…………………………………………………………………………………………
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5. Istirahat dan tidur

 Tidur Siang, Lama : ____________ s/d _____________
 Tidur Malam, Lama : _____________ s/d _____________
 Aktifitas sebelum/sesudah tidur : __________ , _________
Jelaskan:……………………………………………………………………………………………
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6. Penggunaan obat
 Bantuan Minimal
 Bantuan total
Jelaskan:……………………………………………………………………………………………
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7. Pemeliharaan kesehatan
Ya Tidak
Perawatan Lanjutan  
Sistem pendukung  

8. Aktifitas dalam rumah

Ya Tidak
Mempersiapkan makanan  
 Menjaga kerapihan rumah  
Mencuci Pakaian  
Pengaturan keuangan  

9. Aktifitas di luar rumah

Ya Tidak
Belanja  
Transportasi  
Lain-lain  
Jelaskan:……………………………………………………………………………………………
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VIII. MEKANISME KOPING

Adaptif Maladaptif
 Bicara dengan orang lain  Minum alkhohol
 Mampu menyelesaikan masalah  Reaksi lambat/berlebihan
 Teknik relaksasi  Bekerja berlebihan
 Aktifitas konstruktif  Menghindar
 Olah raga  Menciderai diri
 Lain-lain…………….  Lain-lain…………..

Masalah keperawatan : ..............................................................................................

IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

Masalah dengan dukungan kelompok, spesifiknya ...........................................................
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Masalah berhubungan dengan lingkungan, spesifiknya ....................................................
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Masalah dengan pendidikan, spesifiknya…………………......….………………............
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Masalah dengan pekerjaan, spesifiknya ...........................................................................
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Masalah dengan perumahan, spesifiknya …………………..............................................
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Masalah dengan ekonomi, spesifiknya …….........……………………………………....
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Masalah dengan pelayanan kesehatan, spesifiknya…………………………....…….......
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Masalah lainnya, spesifiknya ...........................................................................................
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Masalah keperawatan : ..............................................................................................

X. PENGETAHUAN KURANG TENTANG

Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang kurang tentang suatu
hal?
 Penyakit/gangguan jiwa
 Sistem pendukung
 Faktor presipitasi
 Mekanisme koping
 Penyakit fisik
 Obat-obatan
 Lain-lain, jelaskan
 Jelaskan:……………………………………………………………………………………………
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Masalah keperawatan : ..............................................................................................

XI. ASPEK MEDIS

Diagnosa medik………..…................………………………………………………………...
Terapi medik………..…………………………………………………….....................……...
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XII. DAFTAR MASALAH KEPERAWATAN .

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XIII. POHON MASALAH

XIV. PRIORITAS DIAGNOSA KEPERAWATAN

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Perawat/Mahasiswa *),
*) coret yang tidak perlu

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 RENCANA KEPERAWATAN

Initial pasien : ………………………………………….. Nomor CM : ………………………

Jenis kelamin : L /P. Dx. Medis : ………………………
Ruangan : …………………………………………… Unit Keswa : ………………………

DIAGNOSE TUJUAN & RENCANA TINDAKAN RASIONAL

KEPERAWATAN
 CATATAN PERKEMBANGAN

Initial pasien : ………………………………………….. Nomor CM : ………………………

Jenis kelamin : L /P. Dx. Medis : ………………………
Ruangan : …………………………………………… Unit Keswa : ………………………

NO. DIAGNOSE TINDAKAN KEPERAWATAN EVALUASI KEPERAWATAN

S
 RESUME KEPERAWATAN,

Initial pasien : ………………………………………….. Nomor CM : ………………………

Jenis kelamin : L /P. Dx. Medis : ………………………
Ruangan : …………………………………………… Unit Keswa : ………………………

TANGGAL URAIAN