PENGKAJIAN KEPERAWATAN JIWA

Tgl Pengkajian: ………………………………….

I. Identitas Klien
Nama : ............................................................................................................................
Jenis Kelamin : ............................................................................................................................
Umur : ...........................................................................................................................
Agama : ...........................................................................................................................
Status : ...........................................................................................................................
Pendidikan : ...........................................................................................................................
Alamat : ...........................................................................................................................

II. Riwayat Penyakit Sekarang dan Faktor Presipiasi

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III. Faktor Predisposisi

1. Pernah mengalami gangguan jiwa di masa lalu?
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2. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)?
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3. Pernah ada riwayat NAPZA ?
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4. Riwayat trauma:
a. Aniaya
fisik: ..............................................................................................................................................
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b. Aniaya seksual :
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c. Usaha bunuh diri :
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5. Pengalaman masa lalu yang tidak menyenangkan
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 Masalah keperawatan :
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IV. Riwayat penyakit keluarga

Anggota keluarga yang gangguan jiwa : ..............................................................................................
Gejala : .................................................................................................................................................
Pengobatan : ........................................................................................................................................
Masalah/Diagnosa
Keperawatan: .........................................................................................................................................
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V. Pemeriksaan Fisik
Tanggal : ...............................................................................................................................................
1. Keadaan umum : ............................................................................................................................
2. Tanda-tanda vital:
TD: .................................................................................................................................................
N: ....................................................................................................................................................
RR: .................................................................................................................................................
S: ...................................................................................................................................................
3. Ukuran: TB: .........................................., BB: .................................................................................
4. Kepala : ..........................................................................................................................................
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5. Leher :
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6. Dada
Paru :
Inspeksi : ........................................................................................................................................
Palpasi : .........................................................................................................................................
Perkusi : .........................................................................................................................................
Auskultasi : .....................................................................................................................................
Jantung :
Inspeksi : ........................................................................................................................................
Palpasi : .........................................................................................................................................
Perkusi : .........................................................................................................................................
Auskultasi : .....................................................................................................................................
7. Abdomen :
Inspeksi : ........................................................................................................................................
Auskultasi : .....................................................................................................................................
Perkusi : .........................................................................................................................................
Palpasi : .........................................................................................................................................
8. Tulang Belakang :
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9. Ekstremitas : ..................................................................................................................................
VI. Psikososial
1. Genogram

Keterangan :

Pola asuh :
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Pola komunikasi antar keluarga:
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Pola pengambil keputusan :
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Masalah/Diagnosa Keperawatan : ..............................................................................................
2. Konsep Diri
a. Citra Tubuh
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b. Identitas Diri
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c. Peran Diri
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d. Ideal Diri
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e. Harga Diri
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Masalah/Diagnosa Keperawatan : ..............................................................................................
3. Hubungan Sosial
a. Orang yang berarti
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b. Peran serta dalam kegiatan kelompok atau masyarakat
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c. Hambatan dalam berhubungan dengan orang lain
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Masalah/Diagnosa Keperawatan : .........................................................................................
4. Spiritual
a. Nilai dan keyakinan
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b. Kegiatan Ibadah
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Masalah/Diagnosa Keperawatan : ..............................................................................................

VII. Status Mental

1. Penampilan
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Masalah/Diagnosa Keperawatan : .................................................................................................
2. Pembicaraan
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Masalah/diagnosa Keperawatan : ..................................................................................................
3. Aktivitas motorik/psikomotor
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Masalah/Diagnosa Keperawatan : .................................................................................................
4. Afek dan emosi
a. Afek
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Masalah/diagnosa keperawatan: ………………………………………………………………….
b. Emosi
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Masalah/diagnosa Keperawatan: ………………………………………………………………...
5. Interaksi selama wawancara
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Masalah/ Diagnosa Keperawatan: ................................................................................................
6. Persepsi-sensori
Halusinasi:
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Ilusi: ……………………………………………………………………………………………………….
Derealisasi: ……………………………………………………………………………………………….
Depersonalisasi: …………………………………………………………………………………………
Masalah/DiagnosaKeperawatan: ………………………………………………………………………
7. Proses pikir
a. Arus pikir
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Masalah/Diagnosa Keperawatan: …………………………………………………………………
b. Bentuk pikir
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Masalah/Diagnosa Keperawatan: …………………………………………………………………..
c. Isi pikir
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Masalah Keperawatan: ………………………………………………………………………………
8. Tingkat kesadaran
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9. Memori
Daya ingat jangka Panjang: …….…………………………………………………………………………
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Daya ingat jangka pendek: …………………………………………………………………………………
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Masalah/Diagnosa Keperawatan: ………………………………………………………………………
10.Tingkat konsentrasi dan berhitung
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Masalah/Diagnosa Keperawatan: ………………………………………………………………………
11.Kemampuan penilaian
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Masalah/diagnosa Keperawatan: ………………………………………………………………………
12.Daya tilik
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Masalah/diagnosa Keperawatan: ………………………………………………………………………

XIII. Mekanisme Koping

Adaptif: berbicara dengan orang lain: …………………………………………………………………..
Mampu menyelesaikan masalah: …………………………………………………………….
Teknik relaksasi: …………………………………………………………………………………
Akrivitas konstruktif: ……………………………………………………………………………..
Olahraga: ………………………………………………………………………………………...
Maladaptive: minum alcohol: …………………………………………………………………………………..
Reksi lambat/berlebihan: ……………………………………………………………………….
Menghindar: ……………………………………………………………………………………..
Mencederai diri: ………………………………………………………………………………….
Masalah/diagnosa keperawatan: …………………………………………………………………………..
 XIV. Masalah psikososial dan lingkungan
1. Masalah dengan dukungan kelompok: …………………………………………………………………..
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2. Masalah berhubungan dengan lingkungan social: ………………………………………………………
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3. Masalah yang berhubungan dengan pendidikan: ……………………………………………………….
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4. Masalah yang berhubugan dengan pekerjaan: ………………………………………………………….
5. Masalah yang berhubungan dengan perumahan: …………………………………………………........
6. Masalah berhubungan dengan ekonomi: …………………………………………………………………
7. Masalah berhubungan dengan pelayanan kesehatan : ……………………………………………
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8. Masalah berhubungan dengan sistem hukum: ………………………………………………………….
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Masalah/diagnosa keperawatan: ………………………………………………………………………

XV. Aspek Medis

1. Diagnosa Medis: …………………………………………………………………………………………….
2. Terapi Medis
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XVI. Daftar Masalah Keperawatan

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XVII. Pohon Masalah

Efek

Core problem

etiologi

ANALISA DATA

No Data Etiologi Problem

1. DS :

DO :

DIAGNOSA KEPERAWATAN
1.
2.
3.

RENCANA KEPERAWATAN

No Diagnosa Tujuan Kriteria Hasil Intervensi

TINDAKAN KEPERAWATAN

No Diagnosa Hari/ Tgl/ Jam Implementasi Paraf

EVALUASI KEPERAWATAN

No Diagnosa Hari/ Tgl/ Jam Evaluasi Paraf

S :

O :

A :

P :