PENGKAJIAN KEPERAWATAN
KESEHATAN JIWA
Tanggal MRS : ………………..
TanggalDirawat di Ruangan : ………………..
TanggalPengkajian : ……………........
RuangRawat : …………………
I. IDENTITAS KLIEN
Nama : …………………….. (L/P)
Umur : …………….. ………
Alamat : ………………………
Pendidikan : .....................................
Agama : ....................................
Status : ....................................
Pekerjaan : ………………………
JenisKel. : ………………………
No CM : ………………………
II. ALASAN MASUK
a. DataPrimer
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
b. DataSekunder
..........................................................................................................................................
..........................................................................................................................................
c. KeluhanUtamaSaatPengkajian
..........................................................................................................................................
III. RIWAYAT PENYAKIT SEKARANG (FAKTOR PRESIPITASI)
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
IV. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)
1. Pernahmengalamigangguanjiwa di masalalu?
Ya
Tidak
JikaYa,Jelaskan kapan, tanda gejala/keluhan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
2. Faktor Penyebab/Pendukung :
a. Riwayat Trauma
Usia Pelaku Korban Saksi
1. Aniayafisik ………… ………… ………… …………
2. Aniayaseksual ………… ………… ………… …………
3. Penolakan ………… ………… ………… …………
4. Kekerasandalamkeluarga ………… ………… ………… …………
5. Tindakan kriminal ………… ………… ………… …………
Jelaskan:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan :
b. Pernahmelakukanupaya / percobaan / bunuhdiri
Jelaskan:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
.................................................................................................................................................................
......................................................................................................................................
......................................................................................................................................
DiagnosaKeperawatan :
c. Pengalamanmasalalu yang tidakmenyenangkan (peristiwakegagalan, kematian,
perpisahan )
Jikaadajelaskan :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan :
d. Pernahmengalamipenyakitfisik (termasukgangguantumbuhkembang)
Ya
Tidak
JikayaJelaskan
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan :
e. RiwayatPenggunaanNAPZA
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan :
3. Upaya yang telah dilakukanterkaitkondisi di atas dan hasilnya :
Jelaskan:
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
DiagnosaKeperawatan :
4. RiwayatPenyakitKeluarga
Anggotakeluarga yang gangguanjiwa ?
Ada
Tidak
Jikaada:
Hubungankeluarga:
...........................................................................................................................................
Gejala:
...........................................................................................................................................
Riwayatpengobatan:
...........................................................................................................................................
DiagnosaKeperawatan:
V. PENGKAJIAN PSIKOSOSIAL (Sebelumdansesudahsakit)
1. Genogram:
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan :
2. KonsepDiri
a. Citra tubuh:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
b. Identitas:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
c. Peran:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
d. Ideal diri:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
e. Hargadiri:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
DiagnosaKeperawatan :
3. HubunganSosial
a. Orang yang berarti/terdekat
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
b. Peransertadalamkegiatankelompok/masyarakat dan hubungan sosial
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
c. Hambatandalamberhubungandengan orang lain
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan :
4. Spiritual
a. Nilaidankeyakinan
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
b. Kegiatanibadah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan:
VI. PEMERIKSAAAN FISIK
1. Keadaanumum
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
2. Kesadaran (Kuantitas)
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
3. Tanda vital:
TD : ……. mm/Hg
N :…….. x/menit
S : …….. CO
P : …….. x/menit
4. Ukur:
BB : ……. Kg
TB : ……. Cm
5. Keluhanfisik:
Jelaskan :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan :
VII.STATUS MENTAL
1. Penampilan (Penanpilan usia, cara perpakaian, kebersihan)
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan:
2. Pembicaraan (Frekuensi, Volume, Jumlah, Karakter) :
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan:
3. Aktifitasmotorik/Psikomotor
Kelambatan :
Hipokinesia,hipoaktifitas
Katalepsi
Sub stupor katatonik
Fleksibilitasserea
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Peningkatan :
Hiperkinesia,hiperaktifitas
Stereotipi
GaduhGelisahKatatonik
Mannarism
Katapleksi
Tik
Ekhopraxia
Command automatism
Grimace
Otomatisma
Negativisme
Reaksikonversi
Tremor
Verbigerasi
Berjalankaku/rigid
Kompulsif :sebutkan …………
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan:
4. Mood dan Afek
a. Mood
Depresi Khawatir
Ketakutan Anhedonia
Euforia Kesepian
Lain lain
Jelaskan
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
b. Afek
Sesuai Tidaksesuai
Tumpul/dangkal/datar Labil
Jelaskan:
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
DiagnosaKeperawatan
5. InteraksiSelamaWawancara
Bermusuhan Kontakmatakurang
Tidakkooperatif Defensif
Mudahtersinggung Curiga
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan
6. PersepsiSensorik
a. Halusinasi
Pendengaran
Penglihatan
Perabaan
Pengecapan
Penciuman
b. Ilusi
Ada
Tidakada
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan
7. Proses Pikir
a. ArusPikir:
Koheren Inkoheren
Sirkumtansial Asosiasilonggar
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
Pikiranbunuhdiri o Kebesaran
Preokupasi o Kejar / curiga
Pikiranisolasisosial o Nihilistik
Ide yang terkait o Dosa
PikiranRendahdiri o Sisippikir
Pesimisme o Siar piker
Pikiranmagis o Kontrolpikir
Pikirancuriga Lain lain :
Jelaskan:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
c. Bentuk pikir :
Realistik
Non realistik
Dereistik
Otistik
Jelaskan:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
DiagnosaKeperawatan:
8. Kesadaran
Orientasi (waktu, tempat, orang)
Jelaskan:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Meninggi
Menurun:
Kesadaranberubah
Hipnosa
Confusion
Sedasi
Stupor
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan:
9. Memori
Gangguandayaingatjangkapanjang ( > 1 bulan)
Gangguandayaingatjangkamenengah ( 24 jam - ≤ 1 bulan)
Gangguandayaingatpendek (kurunwaktu 10 detiksampai 15 menit)
Jelaskan:
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
DiagnosaKeperawatan:
10. Tingkat KonsentrasidanBerhitung
a. Konsentrasi
Mudahberalih
Tidakmampuberkonsentrasi
Jelaskan:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
b. Berhitung
Jelaskan:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan:
11. KemampuanPenilaian
Gangguanringan
Gangguanbermakna
Jelaskan :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan:
12. DayaTilikDiri
Mengingkaripenyakit yang diderita
Menyalahkanhal-haldiluardirinya
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan:
VIII. KEBUTUHAN PERSIAPAN PULANG
1. Kemampuanklienmemenuhikebutuhan Perawatankesehatan,
transportasi,
tempattinggal.
Keuangandankebutuhanlainnya.
Jelaskan:
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
2. KegiatanHidupSehariharia. Perawatandiri
1) MandiJelaskan :
......................................................................................................................
......................................................................................................................
......................................................................................................................
2) Berpakaian, berhiasdanberdandan
Jelaskan :
......................................................................................................................
......................................................................................................................
......................................................................................................................
3) MakanJelaskan :
......................................................................................................................
......................................................................................................................
......................................................................................................................
4) Toileting (BAK, BAB)Jelaskan :
......................................................................................................................
......................................................................................................................
......................................................................................................................
DiagnosaKeperawatan:
b. NutrisiBerapafrekwensimakandanfrekwensikudapandalamsehari.
.............................................................................................................................
.............................................................................................................................
Bagaimananafsumakannya
.............................................................................................................................
.............................................................................................................................
Bagaimanaberatbadannya.
.............................................................................................................................
.............................................................................................................................
DiagnosaKeperawatan:
c. Tidur1) Istirahatdantidur
Tidursiang, lama : ____________ s/d _____________
Tidurmalam, lama : _____________ s/d _____________
Aktifitassebelum/sesudahtidur : __________ , _________
Jelaskan
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
2) Gangguantidur
Insomnia Hipersomnia Parasomnia Lain lainJelaskan
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
DiagnosaKeperawatan:
3. Kemampuan lain lain Mengantisipasikebutuhanhidup
....................................................................................................................................
....................................................................................................................................
Membuatkeputusanberdasarkankeinginannya,
....................................................................................................................................
....................................................................................................................................
Mengaturpenggunaanobatdanmelakukanpemeriksaankesehatannyasendiri. ....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan:
4. Sistem Pendukung Ya TidakKeluarga
Terapis
Teman sejawat
Kelompok sosial
Jelaskan :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan:
IX. MEKANISME KOPING
Jelaskan :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
DiagnosaKeperawatan:
X. MASALAH PSIKOSOSIALDAN LINGKUNGAN
Masalahdengandukungankelompok, spesifiknya
Jelaskan :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalahberhubungandenganlingkungan, spesifiknya
Jelaskan :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalahdenganpendidikan, spesifiknya
Jelaskan :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalahdenganpekerjaan, spesifiknya
Jelaskan :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalahdenganperumahan, spesifiknya
Jelaskan :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalahdenganekonomi, spesifiknya
Jelaskan :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalahdenganpelayanankesehatan, spesifiknya
Jelaskan :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalahlainnya, spesifiknya
Jelaskan :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan:
XI. ASPEK PENGETAHUAN
Apakahklienmempunyaimasalah yang berkaitandenganpengetahuan yang
kurangtentangsuatuhal?
Bagaimanapengetahuanklien/keluargasaatinitentangpenyakit/gangguanjiwa,
perawatandanpenatalaksanaanyafaktor yang memperberatmasalah (presipitasi), obat-
obatanataulainnya.Apakahperludiberikantambahanpengetahuan yang
berkaitandenganspesifiknyamasalahtsb.
Penyakit/gangguanjiwa Penatalaksanaan
Sistempendukung Lain-lain, jelaskan
Faktorpresipitasi
Jelaskan :
.................................................................................................................................................
.................................................................................................................................................
DiagnosaKeperawatan:
XII. ASPEK MEDIS
1. Diagnosis Medis :
..........................................................................................................................................
2. Diagnosa Multi Axis
Axis I : ..........................................................................................................................
Axis II :..........................................................................................................................
Axis III :..........................................................................................................................
Axis IV :..........................................................................................................................
Axis V :..........................................................................................................................
.........................................................................................................................................
3. Terapi Medis
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
XIII. ANALISA DATA
NO DATADIAGNOSA
KEPERAWATAN
1. DS:.............................................................................................................................
.............................................................................................................................
DO:.............................................................................................................................
.............................................................................................................................
2. DS:.............................................................................................................................
.............................................................................................................................
DO:.............................................................................................................................
.............................................................................................................................
3. DS:.............................................................................................................................
.............................................................................................................................
DO:.............................................................................................................................
.............................................................................................................................
4. DS:.............................................................................................................................
.............................................................................................................................
DO:.............................................................................................................................
.............................................................................................................................
dst DS:.............................................................................................................................
.............................................................................................................................
DO:.............................................................................................................................
.............................................................................................................................
XIV. DAFTAR DIAGNOSA KEPERAWATAN
1. ………………………………………
2. ………………………………………
3. ………………………………………
4. ………………………………………
5. ………………………………………
6. ………………………………………
7. ………………………………………
8. dst
XV. POHON MASALAH
XVI. PRIORITAS DIAGNOSA KEPERAWATAN
1. ……………………………………………….
2. ………………………………………………
3. ………………………………………………
4. .………………………………………………
Lawang, ……………………….
Mahasiswa yang mengkaji
____________________
NIM................................
TINDAKAN KEPERAWATAN JIWA
Nama :
No CM :
:
No TindakanKeperawatan Evaluasi
Keterangan :
Cara pendokumentasian :
PadakolomTindakanKeperawatandiisi :
Tanggal& jam tindakan
Data (Tanda gejala dan kemampuan)
Diagnosa Keperawatan
Tindakan Keperawatan
KolomEvaluasi:
Evaluasisubyektif&Obyektif
Berdasarkanresponsubyektif, evaluasiobyektif
Sesuaihasilevaluasiresponsubyektif&obyektifpadafaseterminasi
A : AnalisaSesuaikemampuan Pasien
P : Planning , terdiridari P pasiendan P perawat
P pasien : berdasarkanhasilrencanatindaklanjutpadafaseterminasi
P perawat : berdasarkanhasilkontrak yang
akandatangpadafaseterminasi