Lampiran 1

FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

I. IDENTITAS KLIEN
Inisial :
Jenis kelamin :
Umur :
Informan :
Tanggal masuk RS :
Tanggal pengkajian :
Nomor Registrasi :

II. ALASAN MASUK

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

III. FAKTOR PREDISPOSISI

1. Pernah mengalami gangguan jiwa dimasa lalu :
( ) ya, tahun....... ( ) tidak

2. Pengobatan sebelumnya :
( ) berhasil ( ) kurang berhasil ( ) tidak berhasil
3. Masalah penganiayaan : Pelaku/usia
korban/usia saksi/usia

Aniaya fisik

Aniaya seksual

Penolakan

Kekerasan dalam keluarga

Tindakan kriminal

Jelaskan No. 1,2,3 :

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

Masalah keperawatan :

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

4. Adakah anggota keluarga yang mengalami gangguan jiwa ?

( ) ya ( ) tidak

Hubungan keluarga :
....................................................................................................................................................
....................................................................
Gejala :
....................................................................................................................................................
....................................................................................................................
Riwayat pengobatan/ perawatan :
....................................................................................................................................................
....................................................................................................................
5. Pengalaman masa lalu yang tidak menyenangkan? (perceraian/perpisahan/konflik dsb)
....................................................................................................................................................
....................................................................................................................

PEMERIKSAAN FISIK

1. Tanda-tanda Vital TD.......mmhg N.........x/menit

S :...... P.........x/menit
2. Ukur TB........cm BB :... kg
3. Keluhan fisik ( ) ya ( ) tidak
Jelaskan :
.........................................................................................................................................
.......................................................................................................
Masalah keperawatan :
.........................................................................................................................................
.......................................................................................................

IV. PSIKOSOSIAL
1. Genogram
Jelaskan :
.....................................................................................................................................
.....................................................................................................................................
...............................................................................

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

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

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

Masalah keperwatan :
..............................................................................................................................
.........................................................................................
 3. Hubungan Sosial
a. Orang yang berarti :
.......................................................................................................................
.....................................................................................
b. Peran serta kegiatan kelompok/ masyarakat :
.......................................................................................................................
.....................................................................................
c. Hambatan dalam berhubungan dengan orang lain :
.......................................................................................................................
.....................................................................................

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

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

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

V. STATUS MENTAL
1. Penampilan : ( ) tidak rapi
( ) penggunaan pakaian tidak sesuai
( ) cara berpakaian tidak seperti biasanya
Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
2. Pembicaraan : ( ) cepat ( ) keras
( ) gagap ( ) inkoheren
( ) apatis ( ) lambat
( ) membisu ( ) tidak mampu memulai
bicara
Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................

3. Aktivitas motorik : ( ) lesu( ) tegang

( ) gelisah ( ) agitasi
( ) Tik ( ) grimasen
( ) tremor ( ) kompulsif
Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
4. Alam Perasaan : ( ) sedih ( ) ketakutan
( ) putus asa ( ) khawatir
( ) gembira berlebihan
Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
5. Afek : ( ) Datar ( ) Tumpul
( ) labil ( ) Tidak sesuai

Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
6. Interaksi selama wawancara :( ) Bermusuhan
( ) Tidak kooperatif
( ) Mudah tersinggungan
( ) Kontak mata kurang
( ) Defensif
( ) Curiga
Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
7. Persepsi/ Halusinasi : ( ) Pendengaran
( ) penglihatan
( ) Perabaan
( ) pengecapan
 ( ) pengecapan
( ) penghidu
Jelaskan :
Jenis halusinasi :.............................................................
Isi halusinasi :.............................................................
Waktu halusinasi :.............................................................
Frekuensi halusinasi :.............................................................
Situasi halusinasi :.............................................................
Respon klien :.............................................................
..................................................................................................................................
..................................................................................................................................
..............................................................................................
Masalah keperawatan :
..................................................................................................................................
.................................................................................................
8. Proses pikir : ( ) Sircumstansial ( ) Tangensial
( ) Kehilangan asosiasi
( ) flight of idea ( ) Blocking
( ) Pengulangan pembicaraan persevarasi
Jelasakan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................

9. Isi Pikir : ( ) Obsesi ( ) Fobia ( ) Hipokondria

( ) Dipersonalisasi ( ) ide yang terkait
( ) pikiran magis
Waham : ( ) Agama ( ) Somatik ( ) Kebesaran
( ) Curiga ( ) Nihilistik ( ) sisip pikir
 ( ) Siap Pikir ( ) Kontrol Pikir
Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
..................................................................................................................................
..............................................................................................
10. Tingkat kesadaran : ( ) Bingung ( ) Fobia
( ) hipokondria
Disorientasi : ( ) Waktu ( ) Tempat ( ) Orang
Jelaskan :
..................................................................................................................................
................................................................................................

Masalah keperawatan :
..................................................................................................................................
...............................................................................................
11. Memori : ( ) Gangguan daya ingat jangka panjang
( ) Gangguan daya ingat pendek
( ) Gangguan daya ingat saat ini
( ) Konfabulasi
Jelaskan :
..................................................................................................................................
.................................................................................................
Masalah keperawatan ;
..................................................................................................................................
................................................................................................
12. Tingkat konsentrasi dan berhitung :
( ) Mudah bersedih
( ) Tidak mampu berkonsentrasi
( ) Tidak mamapu berhitung sederhana
 Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................

13. Kemampuan Penilaian : ( ) Gangguan ringan

( ) Gangguan Bermakna

Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
14. Daya tarik diri :( ) Mengingkari penyakit yang diderita
( ) Menyalahkan hal-hal yang diluar dirinya

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

VI. PERSIAPAN PULANG

1. Makan dan Minum : ( ) Bantuan minimal
( ) Bantuan total
Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan ;
.................................................................................................................
2. BAB/BAK : ( ) Bantuan minimal ( ) Bantuan total
Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................

3. Mandi : ( ) Bantuan minimal ( ) Bantuan total

Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
4. Berpakaian/berhias : ( ) Bantuan minimal ( ) Bantuan total
Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
5. Istirahat / tidur :
( ) Tidur siang, lama : ...............s/d........................
( ) Tidur malam, lama :................s/d.....................
( ) kegiatan sebelum/ sesudah tidur :....................................
Jelaskan :
..................................................................................................................................
..................................................................................................................................
.............................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
6. Penggunaan obat : ( ) Bantuan minimal ( ) Bantuan total
Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
7. Pemeliharaan Kesehatan :
Perawatan lanjut : ( ) ya ( ) tidak
Perawatan pendukung : ( )ya ( ) tidak
8. Kegiatan didalam rumah :
Mempersiapkan makan : ( ) ya ( ) tidak
Menjaga kerapihan rumah : ( ) ya ( ) tidak
Mencuci pakaian : ( ) ya ( ) tidak
Mengatur keuangan : ( ) ya ( ) tidak
Jelaskan....................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
9. Kegiatan diluar rumah :
Belanja : ( ) ya ( ) tidak
Transportasi : ( ) ya ( ) tidak
Lain-lain : ( ) ya ( ) tidak
 Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................

VII. MEKANISME KOPING

Adaptif
( ) Bicara dengan orang lain
( ) Mampu menyelesaikan masalah
( ) Tehnik relaksasi
( ) Aktivitas konstruktif
( ) Mencederai diri/orang lain/barang
( ) Lain-lain

Mal adaptif
( ) Minum alkohol
( ) Reaksi lambat/ berlebihan
( ) Bekerja berlebihan
( ) Menghindari
Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
VIII. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
Klien berhubungan dengan dukungan kelompok spesifik
...................................................................................................................................
.................................................................................................
 Masalah berhubungan dengan lingkungan fisik
...................................................................................................................................
.................................................................................................
Masalah berhubungan dengan pendidikan spesifik
...................................................................................................................................
.................................................................................................

Masalah berhubungan dengan pekerjaan spesifik

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

Masalah berhubungan dengan perumahan spesifik

...................................................................................................................................
.................................................................................................
Masalah berhubungan dengan ekonomi spesifik
...................................................................................................................................
.................................................................................................
Masalah berhubungan dengan pelayanan kesehatan
...................................................................................................................................
.................................................................................................
Jelaskan :
...................................................................................................................................
.................................................................................................
Masalah keperawatan :
...................................................................................................................................
.................................................................................................

IX. KURANG PENGETAHUAN TENTANG

( ) Penyakit jiwa ( ) Sistem pendukung
( ) Faktror Predisposisi ( ) Kondisi fisik
( ) Mekanisme koping ( ) Obat-obatan
( ) Lain-lain
 Jelaskan :
..................................................................................................................................
................................................................................................
Masalah keperawatan :
..................................................................................................................................
................................................................................................
ASPEK MEDIS
Diagnosa medik :
.................................................................................................................
Terapi medik :
..................................................................................................................................
................................................................................................

X. ANALISA DATA
No DATA MASALAH
 ....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
.................................
....................................................
....................................................
..
XI. POHON MASALAH
............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...............................................
...........................................
 ............................................

XII. DAFTAR DIAGNOSA KEPERAWATAN

a. .....................................................................................
b. .....................................................................................
c. .....................................................................................
d. .....................................................................................
e. .....................................................................................
f. .....................................................................................
g. .....................................................................................
h. .....................................................................................
i. .....................................................................................
j. .....................................................................................
k. .....................................................................................
l. .....................................................................................
m. .....................................................................................
n. .....................................................................................
o. .....................................................................................

Bandar Lampung,.........2020

Mahasiswa
 RENCANA TINDAKAN KEPERAWATAN
Inisial Pasien : Diagnosa Medis :

Ruang : No. RM :

Tgl Dx. Perencanaan

Keperawatan
Tujuan Kriteria Intervensi
Evaluasi
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN
Inisial Pasien : Diagnosa Medis :

Ruang : No. RM :

IMPLEMENTASI EVALUASI
PEMERIX'YAH PROVINSI LAMPUNG

RIIHAH SAKIT JHADAEKAH

Jalan Raya Gcdorig Tataan Km 13 Te1p.(0721) 271170 / Fnx 271171 BANDAR LAMPUNG

Bandar Lempung, 24 Fchruari 2020

890/£a5 /VI1.02/2020 Ytli. Dimlrtur Polts¥Aes Tagjung Karatip

Menjawab Siuat Dimktur Poltckkes Tanjung Karang nomor:

PP.03.0i /1.1/0623/7.020 tanggal 10 Februari 2020 hal. Izin Penelitian,
m&a dfpat kaizil inforgiaslkm her - ml 4ebagal berikut :
1. Pada prinsipnja kami tidak untuk menjadi tempzt penelitian
e sebut, dengan sval u penelitian yaitu 30 (tigs puluh) hari terhitung
mulai z‹ Februari 2020 (daftar name peneliti terlsmpir).
2. Oihurap£an punelifi menyampaikan proposal penelitian kepada Pcngelola
DiKLAT i S. Jlwa Daerah Proiinsi Laiopuog sebelum penelitian

3. Penelitian tersebut di keoakau biaya sesuai dengan PERDA Tarif

penelitian yang berlaku di RS. Jiwa Daerah Pmviosi Lampugg
4. Setelah selesai melakukan porictitien di RS. Jiwa Daerah Provinsi
Lampung peneliti w iib memberikan hasil penelitiunnya kepada
Pengelala DIKL.\T

D RAEWAnmE
SUNG,

200212 l u04
f F’ax 271171
 Persetujuan JuiJi.I KTI/LTA

Judul yang diajukan

Jt1du1 }'ang disetujui

POLO
 SURAT KETERANMN TELAH MEMKUMN ASUMN KEPERAWATAN

Yang bertanda tangan dibañah ini menerangkan bahwa:

Telah melaksanakan asuhan keperawatan dalam. ranéka penyusunan laporan tugas akhir
karya tulis ilmiah terhitung mulal tanggal ”.. .t.. s/d .:. .: bulan ... .
.:........................
tahun .. ..*. .?....... di.Ruañg ?’W- --- ..-.........

Demikian surat keterangan ini dibuat untuk keperluan bukti pelaksanaan asuhan

... ...=^..:...=.T.. .^.. . ...**.. / .... ..... / 203.*.....

Yard Menerangkan
( Kepala Ruan§an’ / Pembimbing /..................”
 PENJELASAN UNTUK MENGIKUT1 PENELITIAN

0'sP)
1. Saya Hesti Rizka Aprillia mahasiswa Politeknik Kesehatan Tanjung
Kamng Jurusan Keperawatan Tanjung Karang Program Studi DIII
Keperawatan Tahun 2020 dengan ini meminta anda untuk berpartisipasi
dengan sukarela dalam pengumpulan data dari tugas akhir yang bequdul Asuhan
Keperawatan Gangguan Pemenuhan Kebutuhan Psikososial Halusinasi Pada
Pasien Skizofrenia Di Rumah Sakit Jiwa Provinsi Lampung tahun 2020.

2. Tujuan dari penulisan adalah menggambarkan asuhan keperawatan jiwa

pada pasien halusinasi dengan pemberian tindakan strategi pelaksanaan
tindakan keperawatan dengan diagnosa Skizofrenia di Rumah Sakit Jiwa
Provinsi Lampung yang dapat memberi manfaat bempa untuk mendapatkan
strategi pelaksanaan yang baik pada pasien halusinasi, pengumpulan data ini
akan berlangsung selama tiga hari.

3. Prosedur pengumpulan data dengan cara pembcrian asuhan keperawatan

selama tiga hari.

4. Keuntungan yang anda peroleh dalam keikutsertaan anda adalah anda turut
terlibat aktivitas mengikuti perkembangan asuhan atau tindakan yang
diberikan.

5. Nama dan jati diri anda beserta seluruh informasi yang anda sampaikan
akan tetap dirahasiakan.

6. Jika anda membutuhkan informasi sehubungan dengan penelitian ini

silahkan menghubungi peneliti pada no. Hp: 089525097609.

PENULIS

Hesti Rizka Aprillia

 POLTEKKESTANJUNGKARANG Kode
PRODIDIIIKEPERAWATANTANJUNGKARANG Tanggal
Lembar Konsultasi Bimbingan Revisi
Laporan Tugas Akhir Halaman
LEMBAR BIMBINGAN KARYA TULIS ILMIAH/LAPORAN TUGAS AKHIR
PEMBIMBING UTAMA

Nama Mshastswa : HESTI RIZKA APRILIA

NIM - 1714401072
Petnbimbing pendamping : Tumiur Sormin, SKM., M. Kes.
Judul Tugas Akhir :Asuhan Keperawatan Gangguan Pemenuhan Kebutuhan
Psikososial Halusinasi Pada Pasien Skizofernia Di Rumah Sakit Jiwa Provinsi Lampung Tahun
2020

No Hari/ Catalan Pembimbing Paraf Mhs Paraf

Tanggal Pembimbing

D ycG«H BRB \V &» \ •¿+H

8 sz-ojcox B k• b• @m @v•i°» I R'
Bandar Lampung, 21 Met 2020
Pembimbing pendamping

Tumiur Sormin, SKM., M. Kes.

NIP. 195804241985fi32004
 POLTEKkESTANJUNGKARANG Kode
PRODTDIIIKEPERAWATANTANJUNGKARANG Tanggal
Lembar Konsultasi Bimbingan Revisi
Laporan Tugas Akhir Halaman
LEMBAR BIMBINGAN KARYA TULIS ILMIAH/LAPORAN TUGAS AKHIR
PEMBIMBING PENDAMPING

Nama Mshasis*’a : HESTI RIZKA APRILIA

NIM : 17144010‘72
I'embimbing pendamping : Yuni Astini, SKM., M. Kes.
Judul Tugas Akhir
Asuhan Keperawatan Gangguan Pemenuhan Kebutuhan Psikososial Halusinasi Pada
Pasien Skizofrenia di Rumah Sakit Jiwa Provinsi Lampung

to Hari/ Catatan Pembimbing Paraf Mhs Paraf

Tanggal Pembimbing

Bandar Lampung, 21 Mei 2020

Pembimbing pendamping

Yun’ Astini, SKM., M.

Kes. NIP.
196806231990032001
 POLTEKKES 7ANJUNGKARANG KEMENKES RI Kode
PRODI D TTT KEPERAWATAN TANJUNGKARANG Tanggal
“ Formulir Revisi
Lembar Masukan dan Perbaikan Halaman

LEMBAR MAS t/ KAN DAN PERBAIKAN

Nama Mahasiswa : Hesti Rizka

Aprillia NIM 1714401072
Tanggal : 24 April 2020
Judui LTA : Asuhan Keperawatan Gangguan Pemenuhan Kebutuhan
Psikososial Halusinasi Pada Pasien Skizofrenia Di Rumah Sakit Jiwa
Provinsi Lampung Tahun 2020

Masukan / Perbaikan KeC Perbaikan

SudahBelu m ]
kesdas 2018 e
halusinasi, isi belum Pendokumentasian2 RS.I, ada pengarahankah
al datang 4.
ampuan): Masalah yang ditemukan apa saja, pohon masalah belum tergambar masalah Pengkajian: Kontrol ke dokter saraf? Psikiater?
dilakukan, berapa lama kegiatan diberikan sd evaluasi? Tanda tangan dan nama perawat Progres dari awal perawatan sd selesai perawatan
sebelum tindakan / orientasi data, tindakan, setelah tindakan evaluasi / terminasi: hasil), adakah inasalah lain yang diangkat, jika tidak mengapa? Kesiinpulan
6
7
8.
9

|0.

Bandar Lampung, Jumat 24 Aptil 2020

Pengesahan setelah perbaikan
oleh:
Anggo Pengujj 1 Anggota Penguji 2
Ket e guji

Ns.Sulastn,S.Kep., .Kep.,Sp.Jiwa Yuniasti i, SKM., M. Kes. Tumiur Sormin, S ., M.

Kes. NIP. 197210151997032002 NIP. 196806231990032001 NIP. 95804241985032004