PENGKAJIAN KEPERAWATAN

KESEHATAN JIWA

Ruang rawat : …………………….…

Masuk rumah sakit :Ke…………….Tgl:………………..
Tanggal dirawat : ……………………….
I. IDENTITAS KLIEN
Inisial : …….. ( L/P ) Usia : ……thn
No. CM : ………….
Alamat
:…………………………………………………………………………………………
………………………………………………………………………………………………….
II. ALASAN MASUK
1. Keluhan utama saat masuk RS……………………………………………............
2. Kondisi saat ini ..............................................................................................................
..............................................................................................................
..............................................................................................................
PRESIPITASI…………………………………………………………………………………
……………………………………………………………………………………………….
III.FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa dimasa lalu ?
Ya
Tidak
2. Pengobatan sebelumnya
Berhasil
Kurang berhasil
Tidak berhasil
3. Trauma : (usia, pelaku/korban/saksi)
Aniaya fisik :……………………………………………………..
Aniaya seksual :……………………………………………………………..
Penolakan : ……….....................................................................................
Kekerasan dalam keluarga : ...................................................................................................
Tindakan kriminal : ...........................................................................................
Jelaskan :
..............................................................................................................

Prodi D III Keperawatan FKIK Unismuh Makassar

..............................................................................................................
Masalah keperawatan
..............................................................................................................
..............................................................................................................
4. adakah anggota keluarga yang mengalami gangguan jiwa
Ya
Tidak
Kalau ada :
Hubungan keluarga :..............................................................................................................
Gejala :.............................................................................................................. .
Riwayat pengobatan/perawatan:............................................................................
Masalah keperawatan
………………………………......................................................................................................
...........................................................................
5. Pengalaman masa lalu yang tidak menyenangkan :
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
Masalah keperawatan
………………………………......................................................................................................
...........................................................................
IV.PEMERIKSAAN FISIK
1. TTV : TD : ……….mmHg N : ……X/mnt
S : …….….°C P :……X/mnt
2. Ukur : BB : ……….kg, TB : ……..cm
3. Keluhan fisik :
..............................................................................................................
..............................................................................................................
..............................................................................................................
Masalah keperawatan
………………………………......................................................................................................
...........................................................................
..............................................................................................................

Prodi D III Keperawatan FKIK Unismuh Makassar

V. PSIKOSOSIAL
1. Genogram :

Ket: Jelaskan masalah yang terkait dengan komunikasi dalam keluarga, pengambilan
keputusan, dan pola asuh.
Jelaskan :
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................

Masalah keperawatan
………………………………......................................................................................................
...........................................................................
2. Konsep diri
a. Citra tubuh :
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
b. Identitas :
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
c. Peran :

Prodi D III Keperawatan FKIK Unismuh Makassar

..............................................................................................................
..............................................................................................................
..............................................................................................................
d. Ideal diri :
..............................................................................................................
..............................................................................................................
..............................................................................................................
e. Harga diri :
..............................................................................................................
..............................................................................................................
..............................................................................................................
Masalah keperawatan
………………………………...................................................................
..............................................................................................................
..............................................................................................................
3. Hubungan sosial
a. Orang yang berarti :
………………………………...................................................................
..............................................................................................................
..............................................................................................................
b. Peran serta dalam kegiatan kelompok/masyarakat
………………………………...................................................................
..............................................................................................................
..............................................................................................................
c. Hambatan dalam berhubungan dengan orang lain :
………………………………...................................................................
..............................................................................................................
..............................................................................................................
Masalah keperawatan
………………………………...................................................................
..............................................................................................................
..............................................................................................................
4. Spiritual
a. Nilai dan keyakinan

Prodi D III Keperawatan FKIK Unismuh Makassar

………………………………...................................................................
..............................................................................................................
..............................................................................................................
b. Kegiatan ibadah :
………………………………...................................................................
..............................................................................................................
..............................................................................................................
Masalah keperawatan
………………………………...................................................................
..............................................................................................................
..............................................................................................................
VI. 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 pembicaraan
Jelaskan : ………………………………...................................................................
Masalah keperawatan .........................................................................................
3. Aktivitas Motorik
Lesu

Prodi D III Keperawatan FKIK Unismuh Makassar

 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 tersinggung
Kontak mata kurang
Defensif
Curiga

Jelaskan :

Prodi D III Keperawatan FKIK Unismuh Makassar

………………………………...................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
Masalah keperawatan
………………………………...................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
7. Persepsi
Halusinasi :
Pendengaran
Penglihatan
Perabaan
Pengecapan
Penciuman
Jelaskan :
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................
8. Isi pikir
Obsesi
Phobia
Hipokondria
Depersonalisasi
Ide yang terkait
Pikiran magis
Waham :
Agama
Somatik
Kebesaran
Curiga
Nihilistik
Sisip pikir
Siar pikir
Kontrol pikir
Jelaskan :
..............................................................................................................
Masalah keperawatan ..............................................................................................................

Prodi D III Keperawatan FKIK Unismuh Makassar

..............................................................................................................
9. Proses pikir
Sirkumstansial
Tangensial
Kehilangan asosiasi
Flight of idea
Blocking
Pengulangan pembicaraan/perseverasi
Jelaskan :
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................
10. Tingkat Kesadaran
Bingung
Sedasi
Stupor
Disorientasi waktu
Disorientasi orang
Disorientasi tempat
Jelaskan : ..............................................................................................................
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................
11. Daya ingat
Gangguan daya ingat jangka panjang
Gangguan daya ingat jangka pendek
Gangguan daya ingat saat ini
Konfabulasi
Jelaskan :
..............................................................................................................
Masalah keperawatan ..............................................................................................................

12. kemampuan berhitung dan konsentrasi

Mudah beralih
Tidak mampu berkonsentrasi
Tidak mampu berhitung sederhana

Jelaskan :
..............................................................................................................

Prodi D III Keperawatan FKIK Unismuh Makassar

Masalah keperawatan ..............................................................................................................
..............................................................................................................
13. Kemampuan penilaian
Gangguan ringan
Gangguan bermakna
Jelaskan :
..............................................................................................................
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................
14. Daya tilik diri
Mengingkari penyakit yang diderita
Menyalahkan hal-hal diluar dirinya
Jelaskan :
..............................................................................................................
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................

VII. KEBUTUHAN PERENCANAAN PULANG

1. Kemampuan klien memenuhi kebutuhan : Ya / Tidak
Makanan ………. ………
Keamanan ………. ………
Perawatan kesehatan ………. ………
Pakaian ………. ………
Transportasi ………. ………
Tempat tinggal ………. ………
Uang ………. ………
Jelaskan :
..............................................................................................................
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................

Prodi D III Keperawatan FKIK Unismuh Makassar

2. Kegiatan hidup sehari-hari
a. Perawatan diri Bantuan Total Bantuan Minimal
Mandi
Kebersihan
Makan
BAB / BAK
Ganti pakaian
Jelaskan :
..............................................................................................................
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................
b. Nutrisi
Apakah anda puas dengan pola makan anda ?
Ya
Tidak
Apakah anda memisahkan diri ?
Ya, jelaskan : ..........................................
Tidak
Frekuensi makan sehari: ..................X
Frekuensi kudapan sehari : ..............X
Nafsu makan :
Meningkat
Menurun
Berlebihan
Sedikit – sedikit
Berat Badan :
Meningkat
Menurun
BB terendah : ..............kg BB tertinggi : ..................kg
Jelaskan :
..............................................................................................................
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................
c. Tidur
1) Apakah ada masalah tidur ?
2) Apakah merasa segar setelah bangun tidur ?

Prodi D III Keperawatan FKIK Unismuh Makassar

3) Apakah ada kebiasaan tidur siang ?
4) Lama tidur siang :................jam
5) Apa yang menolong tidur ? .............................
6) Tidur malam jam : ........, bangun jam .............
7) Apakah ada gangguan tidur ?
Sulit untuk tidur
Bangun terlalu pagi
Somnabulisme
Terbangun saat tidur
Gelisah saat tidur
Berbicara saat tidur
Jelaskan :
..............................................................................................................
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................
3. Kemampuan klien dalam :
Mengantisipasi kebutuhan sendiri
Ya
Tidak
Membuat keputusan berdasarkan keinginan sendiri
Ya
Tidak
Mengatur penggunaan obat
Ya
Tidak
Melakukan pemeriksaan kesehatan (follow up)
Ya
Tidak
Jelaskan :
..............................................................................................................
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................
Klien memiliki sistem pendukung
Keluarga : Ya :........... Tidak : .........
Terapis : Ya : .......... Tidak : .........
Teman sejawat : Ya : .......... Tidak : .........

Prodi D III Keperawatan FKIK Unismuh Makassar

Kelompok sosial : Ya: ........... Tidak : .........
Jelaskan : ..............................................................................................................
..............................................................................................................
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................
..............................................................................................................
Apakah klien menikmati saat bekerja, kegiatan produktif atau hobi ?
Ya
Tidak
Jelaskan :
..............................................................................................................
..............................................................................................................
Masalah keperawatan ..............................................................................................................
..............................................................................................................
VIII. MEKANISME KOPING
Masalah keperawatan ..............................................................................................................
..............................................................................................................
Adaptif :
Bicara dengan orang lain
Mampu menyelesaikan masalah
Teknik relokasi
Aktivitas konstruktif
Olahraga
Lainnya ……………
Maladaptif :
Minum alkohol
Reaksi lambat/ berlebih
Bekerja berlebihan
Menghindar
Mencederai diri
Lainnya…………………
IX. MASALAH PSIKOSOSIAL & LINGKUNGAN
Masalah dengan dukungan kelompok, uraikan
………………………......……………………………………
Masalah dengan pendidikan, uraikan
…..…………………………..................…………………

Prodi D III Keperawatan FKIK Unismuh Makassar

 Masalah dengan pekerjaan, uraikan
………………………......……………………………………
Masalah dengan perumahan, uraikan
………………………......……………………………………
Masalah dengan ekonomi, uraikan
………………………......……………………………………
Masalah dengan pelayanan kesehatan, uraikan
………………………......……………………………………
Masalah lainnya, uraikan
………………………......……………………………………
Masalah keperawatan ..............................................................................................................
..............................................................................................................
X. KURANG PENGETAHUAN TENTANG
Penyakit jiwa
Faktor presipitasi
Koping
Sistem pendukung
Penyakit fisik
Obat-obatan
Lainnya…………………………………........................................
Masalah keperawatan ………………………………................................................................

XI. ASPEK MEDIK

Diagnosis medik : …………………………………………....................................................
Terapi medik : ..............................................................................................................
..............................................................................................................

XII. Pohon Masalah

Prodi D III Keperawatan FKIK Unismuh Makassar

 …………,…………….
Mahasiswa

……………………..

Prodi D III Keperawatan FKIK Unismuh Makassar