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FORMULIR
PENGKAJIAN KEPERAWATAN KESEHATAN JIWA
FIKES- UIA

RUANG RAWAT: FLAMBOYAN TANGGAL DIRAWAT: .15-08-2020

I. IDENTITAS KLIEN
Inisial : Tn. A Tanggal Pengkajian : 18-08-2020
Umur : 28 tahun RM. No. :
Informan :

II. ALASAN MASUK / FAKTOR PRESIPITASI

Karena dirumah suka menyendiri dikamar, kontak mata kurang, diam

III. FAKTOR PREDISPOSISI

1. Pernah mengalami gangguan jiwa masa lalu? √ ya  tidak
2. Pengobatan sebelumnya :  berhasil  Kurang berhasil √ tidak berhasil

3. . Pelaku/Usia Korban/Usia Saksi/Usia

Aniaya fisik

Aniaya seksual

Penolakan

Kekerasan dalam keuarga

Tindakan kriminal

Jelaskan No. 1, 2, 3
: ...............................................................................................
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...............................................
Masalah Keperawatan :

4. Adakah anggota keluarga yang mengalami gangguan jiwa  ya √ tidak

Hubungan keluarga gejala Riwayat penyakit
........................................... ........................................... ...........................................
........................................... ........................................... ...........................................
Masalah keperawatan:
..............................................................................................................................................
5. Pengalaman masa lalu yang tidak menyenangkan

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..............................................................................................................................................
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Masalah Keperawatan :
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IV. FISIK
1. Tanda Vital : TD: ............... N: ............... S: .................... P: ....................
2. Ukur : TB: ............... BB: ...............
3. Keluhan fisik :  Ya  Tidak
Jelaskan: ......................................................................................................................................
......................................................................................................................................................

Masalah Keperawatan:
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V. PSIKOSOSIAL
1. Genogram (3 generasi keatas)

Masalah keperawatan:
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2. Konsep diri:
a. Gambaran diri : ...............................................................................................
...............................................................................................
b. Identitas : ...............................................................................................
...............................................................................................
c. Peran : ...............................................................................................
...............................................................................................
d. Ideal diri : ...............................................................................................
...............................................................................................
e. Harga diri : ...............................................................................................
...............................................................................................
f. Masalah keperawatan: .................................................................................................
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3. Hubungan sosial:

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a. Orang berarti : ....................................................................................................

....................................................................................................
b. Peran serta dalam kegiatan kelompok/masyarakat:
......................................................................................................................................
c. Hambatan dalam berhubungan dengan orang lain:
......................................................................................................................................

Masalah Keperawatan :
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4. Spiritual:
a. Nilai dan keyakinan:
.......................................................................................................................................
.......................................................................................................................................

b. Kegiatan ibadah:
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................

Masalah Keperawatan :
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VI. STATUS METAL

1. Penampilan
 tidak rapi  penggunaan pakaian  Cara berpakaian tidak
tidak sesuai seperti biasanya
Jelaskan: .............................................................................................................................
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Masalah keperawatan:
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2. Pembicaraan
 Cepat  Keras  Gagap  Inkoheren
 Apatis  Lambat  Membisu  Tidak mampu memulai pembicaraan
Jelaskan: .............................................................................................................................
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Masalah Keperawatan:
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3. Aktivitas Motorik

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 Lesu  Tegang  Gelisah  Agitasi

 Tik  Grimasen  Tremor  Kompulsif
Jelaskan: ............................................................................................................................
..............................................................................................................................................

Masalah Keperawatan:
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4. Alam Perasaan
 Sedih  Ketakutan  Putus asa  Kawatir  Gembira berlebihan
Jelaskan: .............................................................................................................................
..............................................................................................................................................

Masalah Keperawatan :
..............................................................................................................................................
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5. Afek
 Datar  Tumpul  Labil  Tidak sesuai
Jelaskan: .............................................................................................................................
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Masalah Keperawatan :
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6. Interaksi selama wawancara

 Bermusuhan  Tidak kooperatif  Mudah tersinggung
 Kontak mata kurang  Defensif  Curiga
Jelaskan: .............................................................................................................................
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Masalah Keperawatan :
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7. Persepsi
 Pendengaran  Penglihatan  Perabaan
 Pengecapan  Penghidu
Jelaskan: ............................................................................................................................
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Masalah Keperawatan :
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8. Proses Pikir

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 Sirkumstansial  Tangensial  Kehilangan asosiasi

 Fligt of ideas  Blocking  Pengulangan pembicaraan/
perseverasi
Jelaskan: ............................................................................................................................
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Masalah Keperawatan :
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9. Isi Pikir
 Obsesi  Fobia  Hipokondria
 Depersonalisasi  Ide yang terkait  Pikiran magis
Jelaskan: ..............................................................................................................................
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Masalah Keperawatan :
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Waham
 Agama  Somatik  Kebesaran  Curiga
 Nihilistik  Sisip pikir  Siar pikir  Kontrol pikir
Jelaskan: ..............................................................................................................................
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Masalah Keperawatan :
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10. Tingkat kesadaran

 Bingung  Sedasi  Stupor
Disorientasi
 Waktu  Tempat  Orang
Jelaskan: ..............................................................................................................................
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Masalah Keperawatan :
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11. Memori
 Gangguan daya ingat jangka panjang  Gangguan daya ingat jangka pendek
 Gangguan daya ingat saat ini  Konfabulasi
Jelaskan: ..............................................................................................................................
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Masalah Keperawatan :
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12. Tingkat konsentrasi dan berhitung

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 Mudah beralih  Tidak mampu berkonsentrasi  Tidak mampu berhitung

sederhana
Jelaskan: ..............................................................................................................................
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Masalah Keperawatan :
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13. Kemampuan penilaian
 Gangguan ringan  Gangguan bermakna
Jelaskan: ..............................................................................................................................
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Masalah Keperawatan :
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14. Daya tilik diri
 Mengingkari penyakit yang diderita  Menyalahkan hal-hal diluar dirinya
Jelaskan: ..............................................................................................................................
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Masalah Keperawatan :
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VII. KEBUTUHAN PERSIAPAN PULANG

1. Makan
√ Bantuan minimal  Bantuan total
2. BAB/BAK
√ Bantuan minimal  Bantuan total

Jelaskan: ..............................................................................................................................
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Masalah Keperawatan :
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3. Mandi
√ Bantuan minimal  Bantuan total
4. Berpakaian/berhias
√ Bantuan minimal  Bantuan total
5. Istirahat dan tidur
 Tidur siang : ....................................................................................................
 Tidur malam : .....................................................................................................
 Kegiatan sebelum dan sesudah tidur: ....................................................................
6. Penggunaan obat
√ Bantuan minimal  Bantuan total

7. Pemeliharaan kesehatan

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Ya Tidak
Perawatan lanjutan  
Sistem pendukung  
8. Kegiatan didalam rumah
Ya Tidak
Mempersiapkan makanan  
Menjaga kerapian rumah  
Mencuci pakaian  
Pengaturan keuangan  
9. Kegiatan diluar rumah
Ya Tidak
Belanja  
Transportasi  
Lain-lain  

Jelaskan: ..............................................................................................................................
..............................................................................................................................................

Masalah Keperawatan :
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VIII. MEKANISME KOPING

Adaptif Maladaptif
 Bicara dengan orang lain  Minum alkohol
 Mampu menyelesaikan masalah  Reaksi lambat/berlebih
 Teknik relaksasi  Bekerja berlebihan
 Aktivitas konstruktif  Menghindar
 Olahraga  Mencederai diri
 Lainnya ....................  Lainnya : ............................................

Masalah Keperawatan:
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................................................................................................................................................

IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

 Masalah dengan dukungan kelompok,

spesifik: ........................................................
....................................................................................................................................

 Masalah berhubungan dengan lingkungan, spesifik: ................................................

..................................................................................................................................

 Masalah dengan pendidikan, spesifik: ....................................................................

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 Masalah dengan perumahan, spesifik: .....................................................................

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 Masalah ekonomi, spesifik: .....................................................................................

..................................................................................................................................

 Masalah dengan pelayanan kesehatan, spesifik: .....................................................

..................................................................................................................................

 Masalah lainnya, spesifik: ......................................................................................

.................................................................................................................................

Masalah Keperawatan:
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X. PENGETAHUAN KURANG TENTANG:

 Penyakit jiwa  Sistem pendukung
 Faktor predisposisi  Penyakit fisik
 Koping  Obat-obatan
 Lainnya .....................................................................................

Masalah Keperawatan:
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XI. ASPEK MEDIK

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

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XIII. ANALISA DATA

NO. MASALAH KEPERAWATAN DATA
1. Halusinasi pendengaran DS :
- klien mengatakan ada suara-suara untuk
menyuruhnya membanting piring,gelas dan Tv
DO :
- klien tampak diam
- klien tampak tidak minum obat secara rutin
2. Harga Diri Rendah DS
- Klien merasa malu karena badannya gemuk
- Klien berharap badannya langsing
- Klien ingin bekerja untuk membantu orang
tuanya
- Klien ingin menikah
DO
- Klien suka menunduk
- Klien suka menyendiri
- Kontak mata klien kurang
3. Isolasi sosial DS
- klien senang dikamar saja
DO
- klien murung dikamar
- klien hanya berdiam diri
- klien selalu menyendiri
- klien menunduk

XIV. BAGAN POHON MASALAH / DIAGNOSA

Efek : Gangguan Persepsi Sensori : Halusinasi Pendengaran

Core Problem :
Isolasi Sosial : Menarik Diri

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Penyebab : Gangguan Konsep Diri : Harga Diri Rendah

XV. DIAGNOSA KEPERAWATAN

1. Gangguan Persepsi Sensori : Halusinasi Pendengaran
2. Isolasi Sosial
3. Gangguan Konsep Diri : Harga Diri Rendah
4. Defisit Perawat Diri
5. Resiko Perilaku Kekerasan/Resiko Mencederai Diri Sendiri
6. Koping Keluarga Inefektif

XVI. RENCANA KEPERAWATAN (RENPRA/NCP)

Dx Dx Perencanaan

Keperawatan Tujuan Kriteria Evaluasi Intervensi

1. Isolasi Sosial : TUM = Setelah 2x interaksi klien 1. Identifikasi

Menarik Diri Klien dapat dapat menyebutkan penyebab isolasi
berinteraksi penyebab isolasi sosial pasien.
denganorang lain a. Tanyakan siapa
TUK = yang paling
1. Klien dapat dekat
menyebutkan b. Siapa yang tidk
penyebab dekat
isolasi c. Apa sebabnya

  TUK 2: Setelah 2x interaksi klien

dapat menyebutkan 2. Diskusi dengan
2. Klien mampu keuntungan punya teman pasien tentang
menyebutkn dan bercakap-cakap keuntungan punya
keuntugan punya teman dan
teman dan bercakap-cakap
bercakap-cakap

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TUK 3: Setelah 2x interaksi klien 3. Diskusikan dengan

dpat menyebutkan pasien tentang
3. Klien mampu kerugian punya teman dan keugian tidak punya
menyebutkan bercakap-cakap teman dan
kerugian tidak bercakap-cakap
punya teman dan
bercakp-cakap

TUK 4: Setelah 2x interaksi klien 4.1 ajarkan pasien cara

dapat melaksanakan berknalan
4. Klien dapat hubungan sosial secara 4.2anjurkan kegiatan
melaksanankan bertahap latihan berkenalan
hubungan sosial berbicara saat
secara bertahap melakukan hubungan
sosial

TUK 5:

5. Klien dapat
5.1evaluasi kegiatan
mempraktekkan latihan berkenalan,
cara berkenalan Setelah 2x interksi klien berbicara saat
dapat berkenalan dan
berbicara saat melakukan kegiatan
berbicara saat melakukan
melakukan harian san sosialisasi
kegiatan harian
kegiatan harian 5.2 ajarkan kegiatan
harian
dan sosialis

XVII. CATATAN KEPERAWATAN DAN EVALUASI

1. Diagnosis Keperawatan
- Isolasi Sosial : Menarik Diri

2. Implementasi dan evaluasi

No. Tanggal dan Jam Implementasi Keperawatan Evaluasi

18 Agustus 2020 1. Mengidentifikasi penyebab isolasi S
16.00 sosial : -Klien mengatakan
1) Siapa yang serumah dirinya serumah
2) Siapa yang dekat dengan Ibu

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3) Siapa yang tidak dekat - Klien mengatakan

4) Apa sebabnya punya teman dekat
2. Mengetahui Keuntungan punya teman namanya Nn”A”
dan bercakap-cakap sebabnya karena ia
3. Mengetahui Kerugian tidak punya baik
teman dan tidak bercakap-cakap - Klien mengatakan
4. Melatih cara berkenalan dengan tidak punya teman
teman,perawat atau tamu tidak dekat
5. Memasukkan pada jadwal kegiatan - Klien mengatakan
untuk latihan berkenalan lebih suka
1) Latihan berkenalan dengan menyendiri
teman kamar 2x sehari - Klien mengatakan
(08:00 dan 15:00) susah mengajak
2) Latihan berkenalan dengan orang lain berbicara
perawat 2x sehari - Klien mengatakan
(11:00 dan 17:00 malas berbicara
dengan orang lain
O
- Klien nampak
Malas bergaul,
beraktifitas sendiri
tampa banyak
bercerita, ekspresi
wajah kurang berseri

A
- Isolasi Soial (+)
P
- Latihan berkenalan
dengan teman kamar
2x sehari (08:00 dan
15:00)
- Latihan berkenalan
dengan perawat 2x
sehari (11:00 dan
17:00)

1. Mengevaluasi kegiatan berkenalan S

(berkenalan dengan teman kamar atau - klien mengatakan
perawat) masih mengingat cara
2. Melatih cara berbicara saat melakukan berkenalan dengan
kegiatan harian teman kamar atau
1) Mengucapkan kata “Trimakasih” perawat
jika berbuat baik - Klien mengatakan

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2) Mengucapkan kata “Minta Maaf” ingin di ajar lagi cara

jika berbuat salah berbicara saat
3. Memasukkan pada jadwal kegiatan melakukan kegiatan
untuk latihan berkenalan harian
1) Latihan berkenalan dengan teman O
kamar 2x sehari - nampak dapat
(08:00 dan 15:00) berkenalan dengan
2) Latihan berkenalan dengan perawat bantuan
2x sehari - Beraktivitas sendiri
(11:00 dan 17:00) tampa adanya
bantuan
- Ekspresi wajah
kurang berserih
A
- Isolasi Sosial (+)
P
- Latihan berkenalan
2-3 orang dan
berbicara saat
melakukan kegiatan
harian
- Latihan berkenalan
dengan teman kamar
2x sehari (08:00 dan
15:00)
- Latihan berkenalan
dengan perawat 2x
sehari
(11:00 dan 17:00)

..................................,......................

Perawat / Mahasiswa,

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