PENGKAJIAN KEPERAWATAN

KESEHATAN JIWA

Tanggal MRS : ………………..

Tanggal Dirawat di Ruangan : ………………..
Tanggal Pengkajian : ……………........
Ruang Rawat : …………………

I. IDENTITAS KLIEN
Nama : Sdr . A (L/P)
Umur : …………….. ………
Alamat : ngawi
Pendidikan : .....................................
Agama : islam
Status : belum menikah
Pekerjaan : tidak memiliki pekerjaan
Jenis Kel. : laki laki
No. CM : ………………………

II. ALASAN MASUK

a. Data Primer
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
b. Data Sekunder
..........................................................................................................................................
..........................................................................................................................................
c. Keluhan Utama Saat Pengkajian
..........................................................................................................................................

III. RIWAYAT PENYAKIT SEKARANG

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

1
 ................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

IV. FAKTOR PRESIPITASI (6 bulan terakhir)

a. Riwayat kesehatan (bio, psiko, sosial, spiritual)
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
Diagnosa Keperawatan :
b. Riwayat bunuh diri (Isyarat, Ancaman, Percobaan)
Jelaskan:
Pasien mengatakan tidak pernah melakukan percobaan bunuh diri

Diagnosa Keperawatan :

V. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)

1. Pernah mengalami gangguan jiwa di masa lalu?
 Ya
 Tidak
Jika Ya, Jelaskan kapan, tanda gejala/keluhan/upaya yg dilakukan dan hasilnya :
............................................................................................................................................................................
............................................................................................................................................................................
............................................................................................................................................................................
Diagnosa Keperawatan :

2. Faktor Penyebab/Pendukung :
a. Riwayat traumatis
Usia Pelaku Korban Saksi
1. Aniaya fisik ………… ………… ………… …………

2
 2. Aniaya seksual ………… ………… ………… …………
3. Penolakan/Pengabaian ………… ………… ………… …………
4. Kekerasan dalam keluarga ………… ………… ………… …………
5. Bullying ………… ………… ………… …………
*) Catatan: isian pelaku, korban, saksi diisi dengan (√)
Jelaskan:
Pasien mengatakan tidak pernah mengalami tindakan criminal ataupun penolakan di masyarakat
Diagnosa Keperawatan :
b. Riwayat bunuh diri (Isyarat, Ancaman, Percobaan)
Jelaskan:
Pasien mengatakan tidak pernah berupaya bunuh diri
Diagnosa Keperawatan :
c. Pengalaman masa lalu yang tidak menyenangkan (peristiwa kegagalan, kematian,
perpisahan )
Jika ada jelaskan :
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
Diagnosa Keperawatan :
d. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
 Ya

 Tidak

Jika ya, Jelaskan:

Pasien mengatkan tidak memiliki keluhan
Diagnosa Keperawatan :
e. Riwayat Penggunaan NAPZA
Pasien mengatakan tidak pernah mengonsumsi napza
Diagnosa Keperawatan :
3. Riwayat gangguan jiwa dalam Keluarga
Anggota keluarga yang gangguan jiwa ?
 Ada
 Tidak
Jika ada :
Hubungan dg klien :
.......................................................................................................................................................
Gejala :

3
 .......................................................................................................................................................
Riwayat pengobatan :
.......................................................................................................................................................
Diagnosa Keperawatan :

VI. PENGKAJIAN PSIKOSOSIAL

1. Genogram:

Jelaskan:
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
Diagnosa Keperawatan :
2. Konsep Diri
a. Citra tubuh :
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
b. Identitas :
.....................................................................................................................................................................................
.....................................................................................................................................................................................

4
 .....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
c. Peran :
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
d. Ideal diri :
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
e. Harga diri :
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
Diagnosa Keperawatan :
3. Hubungan Sosial (di Rumah dan di Rumah Sakit)
a. Orang yang berarti/terdekat
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
b. Peran serta dalam kegiatan kelompok/masyarakat
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
c. Hubungan sosial
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
d. Hambatan dalam berhubungan dengan orang lain
.....................................................................................................................................................................................

5
 .....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
Diagnosa Keperawatan :

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

VII.PEMERIKSAAAN FISIK
1. Keadaan umum
Keadaan umum klien baik , keadaan klien bersih
2. Kesadaran (Kuantitas)
Kesadaran klien compos metis , GCS 456
3. Tanda vital:
TD : 120/80 mm/Hg
N :100 x/menit
O
S : 36,5 C
P : 20 x/menit
4. Ukur:
BB : 65 Kg
TB : 170 Cm
5. Keluhan fisik:
Jelaskan :
Klien mengatakan tidak memiliki keluhan fisik yang dirasakan saat ini
Diagnosa Keperawatan :

VIII. STATUS MENTAL

1. Penampilan (Penampilan umum, cara berpakaian, kebersihan diri)

6
 Jelaskan:
Pasien berpakaian rapi sesuai usia , cara berpakaian benar tidak terbalik, penggunaan pakaian sesuai dengan
fungsinya , badan bersih , gigi bersih , dan memakai sandal
Diagnosa Keperawatan:
2. Pembicaraan (Frekuensi, Volume, Jumlah, Karakter) :
Jelaskan:
Pasien berbicara dengan frekuensi sedang , volume sedang , dan sesuai topik yang dibicarakan
Diagnosa Keperawatan:

3. Aktifitas motorik/ Psikomotor

Kelambatan :
 Hipokinesia,hipoaktifitas
 Katalepsi
 Sub stupor katatonik
 Fleksibilitas serea
Jelaskan:
klienv tidak ada keterlambatan aktifatas motoric atau psikomotor yang dialami klien,
Peningkatan :
 Hiperkinesia, hiperaktifitas  Grimace
 Perilaku Kekerasan  Otomatisme
 Gaduh gelisah, Agitasi, Agresi  Negativisme
 Stereotipi  Reaksi konversi
 Mannerism  Tremor
 Katapleksi  Verbigerasi
 Tik  Berjalan kaku/ rigid
 Ekhopraxia  Kompulsif
 Command automatism
Jelaskan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Diagnosa Keperawatan :
4. Mood dan Afek
a. Mood (alam perasaan)

7
  Depresi  Khawatir
 Ketakutan  Anhedonia
 Euforia  Kesepian
 Marah  Lain lain .......
Jelaskan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
b. Afek (Emosi)
 Sesuai  Tidak sesuai
 Tumpul/Dangkal  Labil
 Datar
Jelaskan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Diagnosa Keperawatan:
5. Interaksi Selama Wawancara
 Bermusuhan  Kontak mata kurang
 Tidak kooperatif  Defensif
 Mudah tersinggung  Curiga
Jelaskan:
Pasien kooperatif saat diajak berbicara
Diagnosa Keperawatan:
6. Persepsi Sensorik
a. Halusinasi
 Pendengaran
 Penglihatan
 Perabaan
 Pengecapan
 Penciuman
b. Ilusi
 Ada
 Tidakada
Jelaskan:
.......................................................................................................................................................

8
 .......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Diagnosa Keperawatan:

7. Proses Pikir
a. Arus Pikir:
 Koheren  Inkoheren

 Sirkumtansial  Asosiasi longgar

 Tangensial  Flight of Idea
 Blocking  Perseverasi

 Logorhoe  Neologisme

 Clang Association  Main kata kata

 Afasia  Lain lain…
Jelaskan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
b. Isi Pikir
 Obsesif  Fobia, sebutkan…………..
 Ekstasi  Waham:

 Fantasi o Agama
 Alienasi o Somatik/hipokondria
 Pikiran bunuh diri o Kebesaran
 Preokupasi o Kejar/curiga
 Pikiran isolasi sosial o Nihilistik
 Ide yang terkait o Dosa
 Pikiran rendah diri o Sisip pikir
 Pesimisme o Siar pikir
 Pikiran magis o Kontrol pikir
 Pikiran curiga  Lain lain :
Jelaskan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

9
c. Bentuk pikir :
 Realistik
 Non realistik
 Dereistik
 Otistik
Jelaskan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Diagnosa Keperawatan:
8. Kesadaran
 Orientasi (waktu, tempat, orang)
Jelaskan:
Orientasi pasien dapat mejawab pertanyaan dengan tepat saat ditanya , pasien bisa
orientasi waktu , tempat dan orang , saat ditanya berada Dimana dijawab benar
 Meninggi
 Menurun:
o Hipnosa
o Confusion
o Sedasi
o Stupor
 Kesadaran berubah
Jelaskan:
Klien dapat merespon pertanyaan dan berkomunikasi 2 arah
Diagnosa Keperawatan:
9. Memori
 Gangguan daya ingat jangka panjang ( > 1 bulan)
 Gangguan daya ingat jangka menengah ( 24 jam - ≤ 1 bulan)
 Gangguan daya ingat pendek ( ≤ 24 jam )
Jelaskan:
Klien dapat mengingat kejadian 2 bulan yang lalu bersama keluarganya, klien dapat
mengingat tanggal lahirnya , dibuktikan dengan pernyataan ibu klien , klien menjawab dengan
benar .Saat ditanya sudah makan klien menjawab sudah
Diagnosa Keperawatan:

10. Tingkat Konsentrasi dan Berhitung

10
 a. Konsentrasi
 Mudah beralih
 Tidak mampu berkonsentrasi
Jelaskan:
Pada saat pengkajian konsentrasi klien tidak mudah terganggu dan sangat focus bercerita
b. Berhitung
Jelaskan:
Baik , dibuktikan saat ditanya “5+10 dijawab 15 “
Diagnosa Keperawatan:
11. Kemampuan Penilaian
 Gangguan ringan
 Gangguan bermakna
Jelaskan :
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Diagnosa Keperawatan:
12. Daya Tilik Diri
 Mengingkari penyakit yang diderita
 Menyalahkan hal-hal di luar dirinya
Jelaskan:
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Diagnosa Keperawatan:
IX. KEBUTUHAN PERSIAPAN PULANG (di Rumah dan RS)
1. Kemampuan klien memenuhi kebutuhan
 Perawatan kesehatan,

 Transportasi,
 Tempat tinggal.
 Keuangan dan kebutuhan lainnya.
Jelaskan:
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

11
2. Kegiatan Hidup Sehari hari
a. Perawatan diri:
1) Mandi
Jelaskan :
Klien dapat mandi mandiri tanpa dibantu , klien mandi 2x sehari pagi hari dan sore hari
2) Berpakaian, berhias dan berdandan
Jelaskan :
Klien dapat menggunakan pakaian sendiri tanpa di bantu , klien bedandan dan memakai
minyak wangi
3) Makan
Jelaskan :
Klien dapat mengambil dan memakanan makananya sendiri tanpa dibantu
4) Toileting (BAK, BAB)
Jelaskan :
Klien dapat BAK dan BAB sendiri tanpa bantuan
Diagnosa Keperawatan:
b. Nutrisi
Berapa frekwensi makan dan frekwensi kudapan dalam sehari.
Klien mendapatkan 3x makan dalam sehari
Bagaimana nafsu makannya
Klien dapat menghabiskan 1 porsi beserta lauk pauknya dalam satu porsi makan
Bagaimana berat badannya.
Klien mengatakan jika berat badannya stabil dan tidak berlebihan
Diagnosa Keperawatan:

c. Tidur
1) Istirahat dan tidur
Tidur siang, lama : 12.00s/d 15.00
Tidur malam, lama : 20.00s/d 06.00
Aktifitas sebelum/sesudah tidur : __________ , _________
Jelaskan
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
2) Gangguan tidur
 Insomnia
 Hipersomnia
 Parasomnia
 Lain lain

12
 Jelaskan
Pasien mengatakan tidur dengan nyenyak
Diagnosa Keperawatan:
3. Kemampuan lain lain
 Mengantisipasi kebutuhan hidup

Klien untuk kebutuhan hidup ditanggung oleh ibunya

 Membuat keputusan berdasarkan keinginannya,
..................................................................................................................................................
..................................................................................................................................................
 Mengatur penggunaan obat dan melakukan pemeriksaan kesehatannya sendiri.
Klien mengatakan selama dirumah obat sudah disiapkan oleh ibunya
Diagnosa Keperawatan:
4. Sistem Pendukung Ya Tidak
Keluarga
Terapis
Teman
Kelompok sosial
Jelaskan :
Klien mengatakan sistem pendukung selama di rumah adalah keluarga
Diagnosa Keperawatan:

X. MEKANISME KOPING
Jelaskan :
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Diagnosa Keperawatan:

XI. MASALAH PSIKOSOSIALDAN LINGKUNGAN

 Masalah dengan dukungan kelompok, spesifiknya
Jelaskan :
Pasien mengatakan tidak mau bersosialisasi dengan masyarakat , pasien kesehariannya
hanya di rumah saja
 Masalah berhubungan dengan lingkungan, spesifiknya
Jelaskan :
Klien mengatakan tidak ada masalah dengan lingkungannya
 Masalah dengan pendidikan, spesifiknya

13
 Jelaskan :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
 Masalah dengan pekerjaan, spesifiknya
Jelaskan :
Pasien tidak memiliki pekerjaan
 Masalah dengan perumahan, spesifiknya
Jelaskan :
Pasien mengatakan tidak ada masalah dengan perumahannya
 Masalah dengan ekonomi, spesifiknya
Jelaskan :
Pasien mengatakan tidak memiliki perkerjaan sehingga ekonominya sulit
 Masalah dengan pelayanan kesehatan, spesifiknya
Jelaskan :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
 Masalah lainnya, spesifiknya
Jelaskan :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Diagnosa Keperawatan:

XII.ASPEK PENGETAHUAN
Bagaimana pengetahuan klien/keluarga tentang :
 Penyakit/gangguan jiwa  Penatalaksanaan
 Sistem pendukung  Lain-lain, jelaskan
 Faktor pendukung dan pencetus
Jelaskan :
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

14
 .....................................................................................................................................................
.....................................................................................................................................................
Diagnosa Keperawatan:

XIII. ASPEK MEDIS

1. Diagnosis Multi Axis
Axis I : ...................................................................................................................................
Axis II : ...................................................................................................................................
Axis III :...................................................................................................................................
Axis IV :...................................................................................................................................
Axis V : ..................................................................................................................................
2. Terapi Medis
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................

15
XIV. ANALISA DATA

DIAGNOSA
NO DATA
KEPERAWATAN
1. DS:

DO:

2. DS:

DO:

3. DS:

DO:

4. DS:

DO:

dst DS:

DO:

16
XV. DAFTAR DIAGNOSA KEPERAWATAN
1. ………………………………………
2. ………………………………………
3. ………………………………………
4. ………………………………………
5. ………………………………………
6. ………………………………………
7. ………………………………………
8. dst

XVI. POHON MASALAH/PATHWAY

XVII. PRIORITAS DIAGNOSA KEPERAWATAN

1. ……………………………………………….
2. ………………………………………………
3. ………………………………………………
4. .………………………………………………

Lawang, ……………………….
Perawat yang mengkaji

____________________
NIM/NIRM: ..………….

17
18
 TINDAKAN KEPERAWATAN JIWA
Nama : Ruang :
No CM : Unit :
Tanggal Diagnosa
No Tindakan Keperawatan Evaluasi Ttd
Jam Keperawatan
*) Keterangan :
Cara pendokumentasian :
1. Mengacu pada fase-fase komunikasi terapeutik
2. Pada kolom waktu diisi : Dx. Kep, tanggal & jam tindakan
3. Pada kolom Tindakan Keperawatan diisi :
a. Fase Orientasi : Saat evaluasi/validasi
b. Fase kerja : Sesuai tindakan fase kerja
c. Fase terminasi : Rencana Tindak Lanjut
4. Kolom Evaluasi:
Evaluasi subyektif & Obyektif
a. Berdasarkan respon subyektif, evaluasi obyektif
b. Sesuai hasil evaluasi respon subyektif & obyektif pada fase terminasi
c. A: Analisa, sesuai dengan hasil interaksi terakhir
d. P: Planning, terdiri dari planning pasien dan perawat
1) Planning pasien: berdasarkan hasil rencana tindak lanjut pada fase terminasi
2) Planning perawat: berdasarkan hasil kontrak yang akan datang pada fase
terminasi