PENGKAJIAN KEPERAWATAN

KESEHATAN JIWA

Tanggal MRS : ………………....

Tanggal Di rawat di Ruangan :………………....
Tanggal Pengkajian : ……………........
Ruang Rawat : ………………….

I. IDENTITAS KLIEN
Nama................................................(L/P)
Umur : ……………..………
Alamat : ……………………..
Pendidikan : ...................................
Agama : ....................................
Status :....................................
Pekerjaan : ………………………
Jenis Kel. : ………………………
No. CM : ………………………

II. ALASAN MASUK

a. Data Primer
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b. Data Sekunder
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c. Keluhan Utama Saat Pengkajian (mengacu untuk penentuan diagnosa)
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III. RIWAYAT PENYAKIT SEKARANG DAN FAKTOR PRESIPITASI

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IV. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)

1. Pernah mengalami gangguan jiwa di masa lalu?
 Ya
 Tidak
JikaYa,Jelaskan kapan, tanda gejala/keluhan :
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2. Faktor Penyebab/Pendukung:
a. RiwayatTrauma
Usia Pelaku Korban Saksi
1. Aniaya fisik ………… ………… ………… …………
2. Aniaya seksual ………… ………… ………… …………
3. Penolakan ………… ………… ………… …………
4. Kekerasan dalam keluarga ………… ………… ………… …………
5. Tindakan kriminal ………… ………… ………… …………
Jelaskan:
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Diagnosa Keperawatan:
b. Pernah melakukan upaya / percobaan / bunuh diri
Jelaskan: ungkapan klien,,tp bukan riwayat
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Diagnosa Keperawatan :
 c. Pengalaman masa lalu yang tidak menyenangkan (peristiwa kegagalan,
kematian, perpisahan)
Jika ada jelaskan :
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DiagnosaKeperawatan :
d. Pernah mengalami penyakit fisik (termasuk gangguan tumbuhkembang)
 Ya
 Tidak
Jika yaJelaskan
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Diagnosa Keperawatan :
e. Riwayat Penggunaan NAPZA
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Diagnosa Keperawatan :
3. Upaya yang telah dilakukan terkait kondisi di atas dan hasilnya :
no 1 dan no 2 Jelaskan:
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Diagnosa Keperawatan :
4. Riwayat Penyakit Keluarga Anggota keluarga yang gangguanjiwa?
 Ada
 Tidak
Jika ada:
Hubungan keluarga :
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Gejala :
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Riwayat pengobatan :
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Diagnosa Keperawatan :

V. PENGKAJIAN PSIKOSOSIAL (Sebelum dan sesudah sakit)

1. Genogram:

Jelaskan:
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Diagnosa Keperawatan :
2. KonsepDiri
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 (di rumah dan diRS)
a. Orang yangberarti/terdekat
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b. Peran serta dalam kegiatan kelompok/masyarakat dan hubungansosial
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c. Hambatan dalam berhubungan dengan orang lain
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Diagnosa Keperawatan :

4. Spiritual
a. Nilai dankeyakinan
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b. Kegiatanibadah
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Diagnosa Keperawatan:

VI. PEMERIKSAANFISIK
1. Keadaanumum
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2. Kesadaran(Kuantitas)
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3. Tandavital:
TD : ……. mm/Hg
N :….........x/menit
S...................O
P...................x/menit
4. Ukur:
BB.............Kg
 TB : ……. Cm
5. Keluhanfisik:
Jelaskan :
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Diagnosa Keperawatan:
VII.STATUSMENTAL
1. Penampilan (Penampilan 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. Aktifitas motorik/Psikomotor
Kelambatan:
 Hipokinesia,hipoaktifitas
 Katalepsi
 Sub stuporkatatonik
 Fleksibilitas serea
Jelaskan:
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Peningkatan :
 Hiperkinesia,hiperaktifitas  Mannarism
 Stereotipi  Katapleksi
 Gaduh GelisahKatatonik  Tik
  Ekhopraxia  Grimace
 Commandautomatism  Otomatisma
Jelaskan:  Negativisme
 Reaksikonversi
 Tremor
 Verbigerasi
 Berjalankaku/rigid
 Kompulsif :sebutkan…………
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Diagnosa Keperawatan:
4. Mood danAfek
a. Mood
 Depresi Khawatir

 Ketakutan Anhedonia

 Euforia Kesepian

 Lain lain
Jelaskan
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b. Afek
 Sesuai Tidaksesuai

 Tumpul/dangkal/datar Labil

Jelaskan:
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Diagnosa Keperawatan: kerusakan komunikasi
5. Interaksi SelamaWawancara
 Bermusuhan Kontak matakurang
 Tidakkooperatif Defensif

 Mudahtersinggung Curiga

Jelaskan:
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Diagnosa Keperawatan
6. Persepsi Sensorik
a. Halusinasi
 Pendengaran
 Penglihatan (ggn mental organik)
 Perabaan
 Pengecapan
 Penciuman
b. Ilusi dpengaruhi oleh kecemasan penyalahgunaan zat
 Ada
 Tidakada
Jelaskan:
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Diagnosa Keperawatan
7. ProsesPikir
a. ArusPikir: menerima informasi, memproses dan mengeluarkan informasi
 Koheren Inkoheren

 Sirkumtansial Asosiasilonggar

 Tangensial Flight ofIdea

 Blocking Perseverasi

 Logorhoe Neologisme

 Clang Association Main katakata

 Afasia Lainlain…

Jelaskan:
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b. IsiPikir
 Obsesif Fobia,sebutkan…………..

 Ekstasi Waham:

 Fantasi o Agama
 Alienasi o Somatik/hipokondria
 Pikiranbunuh diri o Kebesaran
 Preokupasi o Kejar /curiga
 Pikiranisolasisosial o Nihilistik
 Ideyangterkait o Dosa
 PikiranRendahdiri o Sisip pikir
 Pesimisme o Siarpikir
 Pikiranmagis o Kontrol pikir
 Pikirancuriga  Lain lain:
Jelaskan:
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c. Bentuk pikir:
 Realistik
 Nonrealistik
 Dereistik
 Otistik
Jelaskan:
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Diagnosa Keperawatan:

8. Kesadaran ( kualitas) ada hubungan nya dgn waham, HDR, DPD, RPK dan
halusinasi realasi, limitasi,orinetasi dan kta
 Orientasi (waktu, tempat,orang)
Jelaskan:
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 Meninggi
 Menurun:
 Kesadaranberubah
 Hipnosa
 Confusion
 Sedasi
 Stupor
Jelaskan:
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Diagnosa Keperawatan:
9. Memori ( bag. Dari proses pikir)
 Gangguan daya ingat jangka panjang ( > 1bulan)
 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 danBerhitung
a. Konsentrasi
 Mudahberalih
 Tidak mampu
berkonsentrasi Jelaskan:
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b. Berhitung
Jelaskan:
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 Diagnosa Keperawatan:
11. Kemampuan Penilaian bagaimana mengambil keputusan ssi dgn logika
 Gangguanringan
 Gangguan bermakna
Jelaskan:
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Diagnosa Keperawatan:
12. Daya Tilik Diri
 Mengingkari penyakit yangdiderita
 Menyalah kanhal-hal diluar dirinya Jelaskan:
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Diagnosa Keperawatan:

VIII. KEBUTUHAN PERSIAPANPULANG (dikaji saat awal ketemu dgn pasien)

1. Kemampuan klien memenuhi kebutuhan
 Perawatan kesehatan
 transportasi

 tempat tinggal.
 Keuangan dan kebutuhan
lainnya.Jelaskan:
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2. Kegiatan Hidup Seharihari
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 dantidur
Tidur siang,lama : s/d
Tidur malam,lama: s/d
Aktifitas sebelum/sesudah tidur: ,
Jelaskan
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 2) Gangguantidur
 Insomnia
 Hipersomnia
 Parasomnia
 Lain
lainJelaska
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DiagnosaKeperawatan:

3. Kemampuan lainlain
 Mengantisipasi kebutuhan hidup

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 Membuat keputusan berdasarkankeinginannya,
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 Mengatur penggunaan obat dan melakukan pemeriksaan kesehatannyasendiri.
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Diagnosa Keperawatan:
4. Sistem Pendukung Ya Tidak
Keluarga
Terapis
Teman sejawat
Kelompok sosial
Jelaskan :
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Diagnosa Keperawatan:
IX. MEKANISMEKOPING
Jelaskan :
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Diagnosa Keperawatan:

X. MASALAH PSIKOSOSIAL DAN LINGKUNGAN (sumber masalah dgn pasien)

 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. ASPEKPENGETAHUAN
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/gangguanjiwa Penatalaksanaan

 Sistempendukung Lain-lain,jelaskan

 Faktor presipitasi
Jelaskan:
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 Diagnosa Keperawatan:

XII. ASPEK MEDIS

1. Diagnosis MultiAxis (diagnosa medis)
Axis I :.........................................................................................................................
Axis II :........................................................................................................................
Axis III :.........................................................................................................................
Axis IV:.........................................................................................................................
Axis V :........................................................................................................................
2. TerapiMedis
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XIII. ANALISADATA

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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4. DS:
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DO:
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dst DS:
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DO:
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XIV. DAFTAR DIAGNOSAKEPERAWATAN
1. ………………………………………
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6. ………………………………………
7. ………………………………………
8. dst

XV. POHON MASALAH (D3 3 min) (s1 wajib semua ssi dgn daftar diagnosa kep)

XVI. PRIORITAS DIAGNOSA KEPERAWATAN

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

Sukabumi,……………………….
Perawat yang mengkaji

NIM/NIRM: ..………….
 TINDAKAN KEPERAWATAN JIWA
Nama : Ruang:
NoCM : Unit :
Tanggal Diagnosa
No Tindakan Keperawatan Evaluasi Ttd
Jam Keperawatan

1
Keterangan :
Cara pendokumentasian :
 Mengacu pada fasefase komunikasiterapeutik
 Pada kolom waktu diisi : Dx. Kep, Tanggal & jamtindakan
 Pada kolom Tindakan Keperawatan diisi:
 Fase Oreantasi : Saat evaluasi/validasi
 Fasekerja : Sesuai tindakan fasekerja
 Fase terminasi: Rencana TindakLanjut
 KolomEvaluasi:
 Evaluasi subyektif & Obyektif
 Berdasarkan respon subyektif, evaluasi obyektif
 Sesuai hasil evaluasi respon subyektif & obyektif pada faseterminasi
 A : Analisa , Sesuai dengan hasilin teraksiterakhir
 P : Planning , terdiridari P pasien dan Pperawat
 P pasien : berdasarkan hasil rencana tindak lanjut pada faseterminasi
 P perawat : berdasarkan hasil kontrak yang akan datang pada fase
terminasi