PENGKAJIAN KEPERAWATAN
KESEHATAN JIWA
I. IDENTITAS KLIEN
Inisial :___________________________(L/P) Tanggal Pengkajian :_____________________
Umur :___________________________ RM No. :_____________________
Alamat :___________________________
Pekerjaan :___________________________
Informan :___________________________
Bila ya jelaskan___________________________________________________________________
2. Pengobatan sebelumnya Berhasil Kurang Berhasil Tidak Berhasil
3. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
ya tidak
Bila ya jelaskan___________________________________________________________________
RIWAYAT PSIKOSOSIAL
Pelaku/ usia Korban/ usia Saksi/ usia
1. Aniaya fisik
2. Aniaya seksual
3. Penolakan
4. Kekerasan dalam keluarga
5. Tindakan kriminal
Jelaskan :___________________________________________________________________
___________________________________________________________________
6. Pengalaman masa lalu lain yang tidak menyenangkan (bio, psiko, sosio, kultural, spiritual):
____________________________________________________________________________________
__________________________________________________________________________
V. STATUS MENTAL
1. Penampilan
tidak rapi penggunaan pakaian Cara berpakaian
tidak sesuai tidak seperti biasanya
Jelaskan : ______________________________________________________
Masalah keperawatan : ____________________________________________________________
2. Kesadaran
Kwantitatif/ penurunan kesadaran]
compos mentis apatis/ sedasi somnolensia
sopor subkoma koma
Kwalitatif
tidak berubah berubah
meninggi gangguan tidur: sebutkan______________________________
hipnosa disosiasi: sebutkan____________________________________
3. Disorientasi
waktu tempat orang
Jelaskan:
___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
Peningkatan:
hiperkinesia, hiperaktivitas gaduh gelisah katatonik
TIK grimase
tremor gagap
stereotipi mannarism
katalepsi akhopraxia
command automatism atomatisma
nagativisme reaksi konversi
verbigerasi berjalan kaku/ rigit
kompulsif lain-2 sebutkan
5. Afek/ Emosi
adequat tumpul dangkal/ datar
labil inadequat anhedonia
marasa kesepian eforia ambivalen apati
marah depresif/ sedih
cemas: ringan sedang
berat panik
Jelaskan :__________________________________________________________________
Masalah keperawatan :
__________________________________________________________________
6. Persepsi
halusinasi ilusi depersonalisasi
derealisasi
Macam Halusinasi
pendengaran penglihatan perabaan
pengecapan penghidu/ pembauan lain-lain, sebutkan...................
Jelaskan :_________________________________________________________________
Masalah keperawatan :
_________________________________________________________________
7. Proses Pikir
Arus Pikir
koheren inkoheren asosiasi longgar
fligt of ideas blocking pengulangan pembicaraan/ persevarasi
tangansial sirkumstansiality logorea
neologisme bicara lambat bicara cepat
irelevansi main kata-kata afasi
assosiasi bunyi lain2 sebutkan..
Jelaskan :_________________________________________________________________
Masalah keperawatan :
_________________________________________________________________
Isi Pikir
obsesif ekstasi fantasi
bunuh diri ideas of reference pikiran magis
alienasi isolaso sosial rendah diri
preokupasi pesimisme fobia sebutkan.........................
waham: sebutkan jenisnya
agama somatik, hipokondrik kebesaran
curiga nihilistik sisip pikir
siar pikir kontrol pikir kejaran
dosa
Jelaskan :__________________________________________________________________
Masalah keperawatan :
__________________________________________________________________
Bentuk Pikir
realistik nonrealistik
autistik dereistik
8. Memori
gangguan daya ingat jangka panjang gangguan daya ingat jangka pendek
gangguan daya ingat saat ini amnesia, sebutkan.........................
paramnesia, sebutkan jenisnya........................................................
hipermnesia, sebutkan ...................................................................
Jelaskan :_________________________________________________________________
Masalah keperawatan :
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Jelaskan :_________________________________________________________________
Masalah keperawatan :
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Jelaskan :__________________________________________________________________
Masalah keperawatan :
__________________________________________________________________
Jelaskan :__________________________________________________________________
Masalah keperawatan :
__________________________________________________________________
Jelaskan :_________________________________________________________________
Masalah keperawatan :
__________________________________________________________________
VI. FISIK
1. Keadaan umum ____________________________________________________________________
_________________________________________________________________________________
2. Tanda vital: TD:___________N:___________ S:_____________ P:_______
3. UKur: TB:___________ BB:__________ turun naik
4. Keluhan fisik: tidak ya jelaskan...............................
_________________________________________________________________________________
5. Pemeriksaan fisik:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________
Jelaskan
:_____________________________________________________________________
Masalah keperawatan : _____________________________________________________________________
2. Genogram
3. Hubungan Sosial
a. Hubungan terdekat :
______________________________________________________________________________________
______________________________________________________________________
b. Peran serta dalam kelompok/ masyarakat
__________________________________________________________________________________
__________________________________________________________________________
c. Hambatan dalam berhubungan dengan orang lain
__________________________________________________________________________________
__________________________________________________________________________
Masalah keperawatan :
__________________________________________________________________________
4. Spiritual dan kultural
a. Nilai dan keyakinan
__________________________________________________________________________________
__________________________________________________________________________
b. Konflik nilai/ keyakinan/ budaya
__________________________________________________________________________________
__________________________________________________________________________
c. Kegiatan ibadah
__________________________________________________________________________________
__________________________________________________________________________
Masalah keperawatan:
_________________________________________________________________
1. Makan
Bantuan minimal Sebagian Bantuan total
2. BAB/BAK
Bantuan minimal Sebagian Bantuan total
3. Mandi
Bantuan minimal Sebagian Bantuan total
4. Berpakaian/berhias
Bantuan minimal Sebagian Bantuan total
6. Pengginaan obat
Bantuan minimal Sebagian Bantuan total
7. Pemeliharaan kesehatan
Perawatan Lanjutan Ya Tidak
Sistem pendukung Ya Tidak
8. Aktivitas di dalam rumah
Mempersiapkan makanan Ya Tidak
Menjaga kerapihan rumah Ya Tidak
Mencuci pakaian Ya Tidak
Pengaturan keuangan Ya Tidak
Jelaskan :__________________________________________________________________
Masalah keperawatan : ____________________________________________________________
No DATA MASALAH
XV. POHON MASALAH
________________________________________________________________________________________
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________________________________________________________________________________________
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Mahasiswa
______________________________
PROGRAM STUDI S1 KEPERAWATAN
SEKOLAH TINGGI ILMU KESEHATAN BALI
LAPORAN PENDAHULUAN
STRATEGI PELAKSANAAN
TINDAKAN KEPERAWATAN HARI KE..................
A. PROSES KEPERAWATAN
1. Kondisi klien:
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2. Diagnosa keperawatan:
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3. Tujuan khusus:
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4. Tindakan keperawatan:
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2. Evaluasi/ Validasi:
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TERMINASI:
1. Evaluasi respon klien terhadap tindakan keperawatan:
Subyektif:
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Obyektif:
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2. Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan yang telah
dilakukan):
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