FORMAT ASUHAN

KEPERAWATAN JIWA

KELOMPOK GANGGUAN
TIM KEPERAWATAN JIWA

FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH JEMBER
2021
 PENGKAJIAN KEPERAWATAN JIWA

Nama Klien : ..........................................................................................................

Diagnosis Keperawatan : ..........................................................................................................

Mulai di Rawat : ..........................................................................................................

OLEH :

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NIM. …………………………………….

PROGRAM STUDI PROFESI KEPERAWATAN

FAKULTAS ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH JEMBER
2021
 PENGKAJIAN KEPERAWATAN

KESEHATAN JIWA

Tanggal mulai di rawat :

Tanggal Pengkajian :

I. IDENTITAS KLIEN
Nama : ...........................................................
Umur : ...........................................................
Alamat : ...........................................................
Pendidikan : ...........................................................
Agama : ...........................................................
Status : ...........................................................
Pekerjaan : ...........................................................
Jenis Kelamin : ...........................................................

II. ALASAN MASUK

a. Data Primer
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b. Data Sekunder
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c. Keluhan Utama saat pengkajian
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III. RIWAYAT PENYAKIT SEKARANG (FAKTOR PRESIPITASI)

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IV. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)

1. Pernah mengalami gangguan jiwa dimasa lalu ?
 Ya
 Tidak
Jika Ya, jelaskan kapan, tanda/gejala keluhan :
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2. Faktor penyebab / Pendukung
a. Riwayat Trauma
No Uraian 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 :
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b. Pernah melakukan upaya / percobaan / bunuh diri
Jelaskan :
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Diagnosa Keperawatan :
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c. Pengalaman masa lalu yang tidak menyenangkan (peristiwa kegagalan, kematian,
perpisahan )
Jika ada di jelaskan :
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Diagnosa Keperawatan :
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d. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
 Ya
 Tidak
Jika Ya, jelaskan kapan, tanda/gejala keluhan :
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Diagnosa Keperawatan :
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e. Riwayat Penggunaan NAPZA
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3. Upaya yang telah dilakukan terkait kondisi di atas dan hasilnya
Jelaskan :
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4. Riwayat Penyakit Keluarga
 Ya
 Tidak
Jika ada :
Hubungan Keluarga :
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Gejala :
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 Riwayat Pengobatan :
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Diagnosa keperawatan :
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V. PENGKAJIAN PSIKOSOSIAL (Sebelum dan sesudah sakit)
1. Genogram :

Jelaskan :
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Diagnosa Keparawatan :
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2. Konsep Diri
a. Citra Tubuh :
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b. Indetitas :
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c. Peran :
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d. Ideal Diri :
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e. Harga Diri :
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Diagnosa Keparawatan :
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3. Hubungan Sosial
a. Orang yang berarti / terdekat
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b. Peran sertadalam kegiatan kelompok/masyarakat dan hubungan social
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c. Hambatan dalam berhubungan dengan orang lain
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Diagnosa Keparawatan :
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4. Spiritual
a. Nilai dan Keyakinan
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b. Kegiatan Ibadah
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Diagnosa Keparawatan :
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VI. PEMERIKSAAAN FISIK
1. Keadaan Umum
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2. Kesadaran (kuantitas)
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3. Tanda – Tanda Vital
Tensi : ....... / …… mmHg RR : …………x/menit
Suhu : ………oC Nadi : …………x/menit

4. Ukur
5. Keluhan fisik
Jelaskan :
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Diagnosa Keparawatan :
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VII. STATUS MENTAL
1. Penampilan (Penanpilan usia, cara perpakaian, kebersihan)
Jelaskan :
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Diagnosa Keparawatan :
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2. Pembicaraan (Frekuensi, Volume, Jumlah, Karakter)

Jelaskan :
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Diagnosa Keparawatan :
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3. Aktifitas motorik/Psikomotor
Kelambatan
 Hipokinesia, Hipoaktifitas
 Katalepsi
 Sub Strupor Katatonik
 Fleksibilitasserea
Jelaskan :
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Peningkatan :
 Hiperkinesia,hiperaktifitas  Ekhopraxia  Tremor
 Stereotipi  Command automatism  Verbigerasi
 Gaduh Gelisah Katatonik  Grimace  Berjalan kaku / rigid
 Mannarism  Otomatisma  Kompulsif : sebutkan
 Katapleksi  Negativisme
 TIK  Reaksi Konversi
Jelaskan :
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Diagnosa Keparawatan :
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4. Mood dan Afek

a. Mood
  Depresi  Euforia  Anhedonia
 ketakutan  Khawatir  Kesepian
 Lain – lain
Jelaskan :
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b. Afek
 Sesuai  Tidak Sesuai
 Tumpul / dangkal / datar  Labil
Jelaskan :
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Diagnosa Keparawatan :
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5. Interaksi SelamaWawancara
 Bermusuhan  Kontak Mata Kurang
 Tidak Kooperatif  Defensif
 Mudah Tersinggung  Curiga
Jelaskan :
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Diagnosa Keperawatan :
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6. Persepsi Sensorik
a. Halusinasi
 Pendengaran  Perabaan
 Penglihatan  Pengecapan
 Penciuman
Jelaskan :
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b. Ilusi
Ada
  Tidak Ada
Jelaskan :
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Diagnosa Keperawatan :
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7. Proses Pikir
a. Arus Pikir
 Koheren  Inkoheren
  Sirkumtansial  Asosiasi 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 isolasi social o Nihilistik
 Ide yang terkait
o Dosa
 Pikiran Rendah diri
o Sisip piker
 Pesimisme
o Siar piker
 Pikiran magis
 Pikiran curiga
o Kontrol pikir
 Lain – lain ……..
Jelaskan :
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c. Bentuk Pikir
 Realistik  Dereistik
 Non Realistik  Otistik
Jelaskan :
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Diagnosa Keperawatan :
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8. Kesadaran
 Orientasi ( waktu, tempat, orang )
 Meninggi
 Menurun
o Kesadaran Berubah  Sedasi
o Hipnosa  Stupor
o Confusion

Jelaskan :
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Diagnosa Keperawatan :
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 9. Memori
 Gangguan daya Ingat Jangka Panjang ( > 1 bulan )
 Gangguan daya Ingat Jangka Menengah (24 jam - ≤ 1 bulan )
 Gangguan daya Ingat Jangka Pendek (Kurun waktu 10 detik s/d 15 Menit )
Jelaskan :
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Diagnosa Keperawatan :
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10. Tingkat Konsentrasi dan Berhitung

a. Konsentrasi
 Beralih
 Tidak Mampu Konsentrasi
Jelaskan :
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b. Berhitung
Jelaskan :
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Diagnosa Keperawatan :
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11. Kemampuan Penilaian

 Gangguan Ringan
 Gangguan Bermakna
Jelaskan :
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Diagnosa Keperawatan :
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12. Daya Tilik Diri

 Mengingkari Penyakit yang Diderita
 Menyalahkan hal – hal diluar dirinya
Jelaskan :
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Diagnosa Keperawatan :
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VIII. PEMENUHAN KEBUTUHAN SEHARI-HARI

1. Kemampuan klien memenuhi kebutuhan
 Perawatan Kesehatan  Tempat tinggal
 Transportasi  Keuangan dan kebutuhan lainnya
 Jelaskan :
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2. Kagiatan 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 (BAB dan BAK)
Jelaskan :
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b. Nutrisi
 Berapa frekuensi makan dalam sehari
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 Bagaimana nafsu makannya
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 Bagaimana berat badannya
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Diagnosa Keperawatan :
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c. Tidur
1) Istirahat dan Tidur
 Tidur siang, lama : …………… s/d ……………….
 Tidur malam, lama : …………… s/d ……………….
 Aktifitas sebelum dan sesudah tidur : ………………… , ………………....
Jelaskan :
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2) Gangguan Tidur
 Insomnia  Parasomnia
 Hypersomnia  Lain – lain
Jelaskan :
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Diagnosa Keperawatan :
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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 :
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4. System pendukung
Uraian 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 :
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X. MASALAH PSIKOSOSIAL DAN 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 kesehatan, spesifiknya
Jelaskan :
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 Masalah lainnya, spesifiknya
Jelaskan :
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Diagnosa Keperawatan :
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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 perludi berikan tambahan pengetahuan yang berkaitan dengan spesifiknya
masalah tsb.
 Penyakit / gangguan jiwa  Penatalaksanaan
 Sistem pendukung  Lain – lain, jelaskan
 Faktor Presipitasi
Jelaksan :
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Diagnosa Keperawatan :
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XII. ASPEK MEDIS
1. Diagnosa Medis
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2. Diagnosa multi axis
 Axis I : ...............................................................................................................
 Axis II : ...............................................................................................................
 Axis III : ...............................................................................................................
 Axis IV : ...............................................................................................................
 Axis V : ...............................................................................................................
3. Terapi Medis
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XIII. ANALISA DATA

DIAGNOSA
NO DATA
KEPERAWATAN
1 Data Subjektif :
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Data Objektif :
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2 Data Subjektif :
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Data Objektif :
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3 Data Subjektif :
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Data Objektif :
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4 Data Subjektif :
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Data Objektif :
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dst Data Subjektif :
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Data Objektif :
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XIV. DAFTAR DIAGNOSA KEPERAWATAN
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8. ......................................................................................................................................
9. Dst

XV. POHON MASALAH

XVI. PRIORITAS DIAGNOSA KEPERAWATAN

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4. .........................................................................................................................................

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Mahasiswa yang mengkaji

( …………………………………….. )
NIM.