Prodi D III KEPERAWATAN

N A M A : …………………………
PROVINSI DKI JAKARTA 2012 NIM : …………………………

ASUHAN KEPERAWATAN JIWA

A. PENGKAJIAN
Tanggal Pengkajian : ______________ Nomor Register : _____________

Ruangan Rawat : ______________ Diagnosa Medis : ______________

Tanggal Dirawat : ______________

1. IDENTITAS KLIEN
Nama : …………..(L/P)

Umur : ……………….

Status Perkawinan : ……………….

Agama : ……………….

Suku Bangsa : ……………….

Pendidikan : ……………….

Alamat : ……………….

Sumber Informasi : ……………….

2. ALASAN MASUK
_________________________________________________________________

_________________________________________________________________

_________________________________________________________________
_________________________________________________________________

3. FAKTOR PREDISPOSISI
a. Pernah mengalami gangguan jiwa di masa lalu ? ( ) Ya ( ) Tidak
b. Pengobatan sebelumnya. ( ) Berhasil ( ) Kurang Berhasil
( ) Tidak Berhasil

c. Pelaku/Usia Korban/Usia Saksi/Usia

Aniaya Fisik ( ) ( ) ( ) ( ) ( ) ( )

Aniaya Seksual ( ) ( ) ( ) ( ) ( ) ( )

Penolakan ( ) ( ) ( ) ( ) ( ) ( )

Kekerasan dalam keluarga ( ) ( ) ( ) ( ) ( ) ( )

Tindakan kriminal ( ) ( ) ( ) ( ) ( ) ( )

Jelaskan a, b dan c :

___pernah megalami ggn jiwa

tahun ....___________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan :

a. regiment terapeutik ineefktif,

b. koping kelg inefektif

c rpk

______________________________________________________________

______________________________________________________________

______________________________________________________________
 d. Adakah anggota keluarga yg mengalami gangguan jiwa ( ) Ya ( ) Tidak
Hubungan keluarga Gejala Riwayat pengobatan/perawatan

________________ ______________ _______________________

________________ ______________ _______________________

e. Pengalaman masa lalu yang tidak menyenangkan

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan ISOLASI

SOSIAL_________________________________________

______________________________________________________________

______________________________________________________________

4. PEMERIKSAAN FISIK
a. Tanda vital : TD : _____________ N : _____________
S : _____________ P : _____________

b. Ukur : TB : _____________ BB : _____________

c. Keluhan fisik : ( ) Ya ( ) Tidak
Jelaskan :

_________________________pusing_____________________________________

______________________________________________________________

______________________________________________________________
 Masalah Keperawatan __nyeri _________________________________________

______________________________________________________________

______________________________________________________________

5. PSIKOSOSIAL
a. Genogram : Gambarkan

Jelaskan :

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Masalah Keperawatan __koping keluarga

inefektif_______________________________________

_____________________________________________________________
 _____________________________________________________________

b. Konsep diri
1) Gambaran diri : __tdk suka dengan rambutnya
_________________________________________
___________________________________________

___________________________________________

___________________________________________

2) Identitas : ___________________________________________
___________________________________________

___________________________________________

3) Peran : ___________________________________________
___________________________________________

___________________________________________
___________________________________________

4) Ideal diri : ___________________________________________

___________________________________________

___________________________________________
___________________________________________

5) Harga diri : klien merasa tdk berharga MALU, TDK PD. TDK
BERGUNA_______________________________________
___
___________________________________________
___________________________________________
___________________________________________
 Masalah Keperawatan __ HDR_______________________________

______________________________________________________________

_______________________________________________________________

c. Hubungan Sosial
1) Orang yang berarti :
___ayahnya______________________________________
___________________________________________________________

___________________________________________________________

___________________________________________________________

2) Peran serta dalam kegiatan kelompok/masyarakat :

_________tdk aktif dlm berbagai
kegiatan__________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

3) Hambatan dalam berhubungan dengan orang lain :

_______malas bicara dan tdk bisa memulai
pembicaraan____________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________
 Masalah Keperawatan __________isolasi
sosial_________________________________

______________________________________________________________

______________________________________________________________

d. Spiritual
1) Nilai dan keyakinan :
___________________________________________________________

___________________________________________________________

___________________________________________________________

2) Kegiatan ibadah :
___________________________________________________________

___________________________________________________________

___________________________________________________________

6. STATUS MENTAL
a. Penampilan
( v ) Tidak rapi ( v ) Penggunaan pakaian tidak sesuai

( v ) Cara berpakaian tidak seperti biasanya

Jelaskan : ____pakaian tdk sesuai, rambut td rapih bau

badan_____________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan __________DPD_________________________________

_______________________________________________________________
_______________________________________________________________

b. Pembicaraan
( v ) Cepat ( v ) Keras ( ) Gagap ( ) Inkoheren ( ) Apatis

( ) Lambat ( ) Membisu ( ) Tidak mampu memulai pembicaraan

Jelaskan : ___RPK (cpt, krs) isos ( lambat, membisu tdk mampu

memulai pemb, APATIS) PSP halu ( cepat, keras, inkoheren) HDR (gagap, lambat,
apatis)_____________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan ___ISOS________________________________________

_______________________________________________________________

_______________________________________________________________

c. Aktivitas Motorik
( V ) Lesu ( ) Tegang ( ) Gelisah ( ) Agitasi

( ) Tik ( ) Grimasen ( ) Tremor ( ) Kompulsif

Jelaskan : KLIEN MENGATAKAN LESU , TDK ADA TENAGA UNTUK

BICARA___________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________
______________________________________________________________

Masalah Keperawatan _______ISOS___________________________________

______________________________________________________________

______________________________________________________________

d. Alam perasaan
(V ) Sedih ( ) Ketakutan ( ) Putus asa

( ) Khawatir ( ) Gembira berlebihan

Jelaskan : __KLIEN MENGAKAN SEDIH KRN TDK PUNYA TEMAN,

….______________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan ___ISOS_______________________________________

______________________________________________________________

______________________________________________________________

e. Afek
( V ) Datar ( ) Tumpul ( ) Labil ( ) Tidak sesuai

Jelaskan : _________________________________________

___EKSPRESI WAJAH KLIEN SAAT DIAJAK BICARA TIDAK ADA

PERUBAHAN___________________________________________________________

______________________________________________________________

______________________________________________________________
______________________________________________________________

Masalah Keperawatan _____ISOS_____________________________________

______________________________________________________________

______________________________________________________________

f. Interaksi selama wawancara

( ) Bermusuhan ( ) Tidak kooperatif ( ) Mudah tersinggung

( V ) Kontak mata kurang ( ) Defensif ( ) Curiga

Jelaskan : _SAAT BICARA KONTAK MATA KLIEN

KURANG________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan ____ISOS___DAN

HDR___________________________________

______________________________________________________________

______________________________________________________________

g. Persepsi
Halusinasi

( v ) Pendengaran ( v ) Penglihatan ( ) Perabaan

( ) Pengecapan ( ) Penghidu
Jelaskan : __isi : suara bapaknya, frekuensi 2-3 x/hr, waktu : pagi.
Siang, malam, respon apa yg dirasakan saat halu : sedih, senag , apa yg dilakukan saat
halu : diam aja_, meng_ikuti halu_____________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan ________psp halusinasi pendengaran dan

penglihatan__________________________________

______________________________________________________________

______________________________________________________________

h. Proses Pikir
( ) Sirkumstansial ( ) Tangensial ( ) Kehilangan asosiasi

( v ) Flight of ideas ( v ) Blocking

( ) Pengulangan pembicaraan/persevarasi

Jelaskan : _________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan __________________________________________

______________________________________________________________

______________________________________________________________

i. Isi pikir
( ) Obsesi ( ) Fobia ( ) Hipokondria

( ) Depersonalisasi ( ) Ide yang terkait ( ) Pikiran magis

Waham :

( ) Agama ( ) Somatik ( ) Kebesaran ( ) Curiga

( ) Nihilistik ( ) Sisip pikir ( ) Siar pikir ( ) Kontrol pikir

Jelaskan : _________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan __________________________________________

______________________________________________________________

______________________________________________________________

j. Tingkat Kesadaran
( ) Bingung ( ) Sedasi ( ) Stupor

Disorientasi :

( ) Waktu ( ) Tempat ( ) Orang

Jelaskan : _________________________________________

______________________________________________________________
______________________________________________________________

______________________________________________________________

Masalah Keperawatan __________________________________________

______________________________________________________________

______________________________________________________________

a. Memori
( ) Gangguan daya ingat jangka panjang

( ) Gangguan daya ingat jangka pendek

( ) Gangguan daya ingat saat ini ( ) Konfabulasi

Jelaskan : _________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan __________________________________________

______________________________________________________________

______________________________________________________________

b. Tingkat konsentrasi dan berhitung

( ) Mudah beralih ( ) Tidak mampu berkonsentrasi

( ) Tidak mampu berhitung sederhana

Jelaskan : _________________________________________

______________________________________________________________

______________________________________________________________
______________________________________________________________

Masalah Keperawatan __________________________________________

______________________________________________________________

______________________________________________________________

c. Kemampuan Penilaian
( ) Gangguan ringan ( ) Gangguan bermakna

Jelaskan : _________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan __________________________________________

______________________________________________________________

_____________________________________________________________

d. Daya tilik diri

( ) Mengingkari penyakit yang di derita

( ) Menyalahkan hal-hal di luar dirinya

Jelaskan : _________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan __________________________________________

______________________________________________________________

______________________________________________________________
7. KEBUTUHAN PERSIAPAN PULANG
a. Makan
( ) Bantuan minimal ( ) Bantuan total

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

b. BAB/BAK
( ) Bantuan minimal ( ) Bantuan total

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

c. Mandi
( ) Bantuan minimal ( ) Bantuan total

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

3. Berpakaian/berhias
( ) Bantuan minimal ( ) Bantuan total

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

4. Istirahat dan tidur

( ) Tidur siang lama: ……………………… s/d ………………….

( ) Tidur malam lama : ……………………... s/d ……………………

 ( ) Kegiatan sebelum/sesudah tidur

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

5. Penggunaan obat
( ) Bantuan minimal ( ) Bantuan total

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

6. Pemeliharaan kesehatan Ya Tidak

Perawatan lanjutan ( ) ( )

Sistem pendukung ( ) ( )

_____________________________________________________________

_____________________________________________________________

Kegiatan di dalam rumah Ya Tidak

Mempersiapkan makanan ( ) ( )
Menjaga kerapihan rumah ( ) ( )

Mencuci pakaian ( ) ( )

Pengaturan keuangan ( ) ( )

_____________________________________________________________

_____________________________________________________________
 7. Kegiatan di luar rumah Ya Tidak
Belanja ( ) ( )

Transportasi ( ) ( )

Lain – lain ( ) ( )

Jelaskan : _______________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan __________________________________________

______________________________________________________________

______________________________________________________________

8. MEKANISME KOPING
Adaftif Maladaftif
( ) Bicara dengan orang lain ( ) Minum Alkohol

( ) Mampu menyelesaikan masalah ( ) Reaksi lambat / berlebih

( ) Teknik relaksasi ( ) Bekerja berlebihan

( ) Aktivitas konstruktif ( ) Menghindar

( ) Olahraga ( ) Mencederai diri

( ) Lainnya ………………………. ( ) Lainnya ……………….

Jelaskan : _________________________________________

______________________________________________________________

______________________________________________________________

Masalah Keperawatan __________________________________________

 ______________________________________________________________

______________________________________________________________

9. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

( ) Masalah dengan dukungan kelompok, spesifik klien merasa tdkpernah di dukung

oleh klp_____________________
________________________________________________________________
( ) Masalah berhubungan dengan lingkungan, spesifik _________________
________________________________________________________________
( ) Masalah dengan pendidikan, spesifik ___klien merasa bodoh krn tdk
lulus_________________________
________________________________________________________________
( ) Masalah dengan pekerjaan, spesifik _____klien merasa tdk berharga krn tdk
bekerja________________________
________________________________________________________________
( ) Masalah dengan perumahan, spesifik ____________________________
________________________________________________________________
( ) Masalah ekonomi, spesifik ____________________________________
________________________________________________________________
( ) Masalah dengan pelayanan kesehatan, spesifik _____________________
________________________________________________________________
( ) Masalah lainnya, spesifik _____________________________________
________________________________________________________________
( ) Masalah dengan dukungan lingkungan, spesifik ___________________
________________________________________________________________
Masalah Keperawatan ____________________________________________

________________________________________________________________

________________________________________________________________

10. PENGETAHUAN KURANG TENTANG :

( ) Penyakit Jiwa ( ) Sistem pendukung ( ) Faktor presipitasi

( ) Penyakit fisik ( ) Koping ( ) Obat-obatan ( ) Lainnya

Masalah Keperawatan ____________________________________________

 ________________________________________________________________

________________________________________________________________

11. ASPEK MEDIK

Diagnosa medik :
___Scizoprenia
__________________________________________________________________
___________________________________________________________
Terapi medik : __CPZ 5 mg 3 x 1
tab______________________________________________________________
________________________________________________________________

Jakarta, ………………………..2010

Mahasiswa

(……………………………)

12. ANALISA DATA

Initial Nama : ____________ Ruangan : ____________ No. RM : __________

TANGGAL / JAM DATA FOKUS MASALAH KEPERAWATAN

5 feb 2021 DS RPK

09.00 DO

DS PSP Halu

DO
 13. POHON MASALAH

RPK

PSP : Halusinasi Pendengaran dan penglihatan

Regiment terapeutik inefk

Isos DPD

Koping keluarga inefektif

RESIKO PSP : HALUSINASI

ISOS DPD

HDR

KEHILANGAN/PENOLAKAN

1. ISOS (CP/MASALAH UTAMA/DIAGNOSA UTAMA)

2. HDR
3. DPD
1. HDR
2. ISOS
3. DPD/RPSP ; HALUSINASI
 1. PSP :HALUSINASI
2. ISOS
3. RESIKO MENCEDERAI DIRI SENDIRI, ORG LAIN DAN LINGK

B. DAFTAR DIAGNOSA KEPERAWATAN

1. PSP Halu

2. Isos

3. DPD

4. KKIE

5 RTIE

6 RPK
C. RENCANA TINDAKAN KEPERAWATAN

INITIAL KLIEN : __________ RUANGAN : ___________ RM NO : __________

No DX Perenc

Tujuan Kriteria E
Diagnosa Keperawatan

   1 s;d ….pertemuan  

     

     

     

     

     

     

     

     

     

     

     

     
Jakarta, …………………

Mahasiswa

(………………………)
D. IMPLEMENTASI DAN EVALUASI

Initial Nama : _________ Ruangan : __________ No.RM : ___________

HARI/ NO.DX.
TINDAKAN NAMA/
KEP/ EVALUASI
TGL/ JAM KEPERAWATAN PARAF
SP