ASUHAN KEPERAWATAN JIWA PADA Ny.

DENGAN DEFISIT PERAWATAN DIRI

Di Ruang SRIKANDI

RSJD AMINO GONDOHUTOMO SEMARANG

Di Susun Oleh :

RINI INNAFI!AH

PRODI S" KEPERAWATAN

FAKUTAS
FAKUTAS IMU
IM U KEPERAW
KEPE RAWA
ATAN
TAN

UNI#ERSITAS ISAM SUTAN AGUNG

SEMARANG

$%"&
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PENGKAJIAN KEPERAWATAN JIWA

PENGKAJIAN

Hari/Tanggal
Hari/Tanggal : Senin, 16 juni 2014

Oleh : RINI LINNAFIYAH

Ruang : Srikani

A! Ien
Ien""i"a#
i"a#

Ien"i"a# klien

 Na$a : N%! N

&#ia : 40 "ahun

'eni# (ela$in : )ere$*uan

Aga$a : I#la$

Ala$a" : #e$arang

Tanggal +a#uk : 16 $ei 2014

 N!R+ : 06!40!-6

Ien"i"a# )enanggung 'a.a

 Na$a : Tn! 

&#ia : 4

Ala$a" : #e$arang
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! Ala#
Ala#an
an +a#u
+a#uk 
k 

(lien ia.a keluarga ke RS' A$in 3nhu"$ engan keluhan #e$enjak i "inggal
 a*ak klien #ering $ela$un, #uli" "iur, klien iara #eniri, iara "iak n%a$ung, #uka
kelu%uran, "iak $au $akan an $ani 5 6 ulan "iak $inu$ a"!

+a#alah ke*era.a"n : ei#i" *era.a"an iri

7! Fak"
Fak"r
r )rei#
)rei#*
*#i
#i#i
#i

(lien #eelu$n%a *ernah ira.a" i R# 'i.a #a$*ai 8 kali kurang leih 6 ulan "iak 
 *ernah $inu$ a", ala$ keluarga klien "iak aa %ang $engala$i gangguan ji.a!
Sejak a*ak%a $eniggal unia *a#ien "erliha" #ering $ela$un, $urung, "iak $au $akan
an $ani, $ani haru# i#uruh! )a#ien "iak *ernah $egala$i ania%a i#ik $au*un
kejaian %ang "iak $en%enangkan!

! Fi#ik 

1! Tana
na 9i
9i"al
"al

T : 120/0 $$Hg

 N : 2; / $eni"

S : 86<7

RR : 20;/$eni
20;/$eni""

2! &kuran

T : 1-6 $  : -0kg
-0kg

8! (el
(eluhan
uhan Fi#i
Fi#ik
k : kli
klien
en "iak
iak aa
aa $e$
$e$il
ilik
ikii kel
keluh
uh#n
#n i#
i#ik 
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=! )#i
)#ik#
k##ia
#iall

1! 3engra$

(e"erangan :

: Laki>Laki

: (lien

: )ere$*uan

: +eninggal

2! (n#e* iri

a! 3a$
3a$ara
aran
n iri
iri

(lien $ega"akan $e%ukai angg"a "uuh *aa agian hiung an "iak $en%ukai
 agian angg"a "uuhn%a %ai"u gigi karena gigin%a $*ng!

 ! Ien"i"a#

(lien $enga"akan *ua# $enjai anak *ere$*ua karena klien #elalu $e$an"u
iun%a $e$er#ihkan ru$ah an i#a $era.a" a%ahn%a %ang #eang #aki"!

! )eran

(lien $enga"akan *ua# $enjai anak ke>2 ari 4 er#auara! (arena klien $era#a
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! Ieal i
iri

(lien $ega"akan .ak"u keil $e$*un%ai i"a>i"a ingin $ejai guru an #e"elah
 e#ar klien ingin $e$ahagiakan rang "uan%a an erak"i ke*aa rang "uan%a!

e! Harg
arga iri

Sela$a iru$ah klien $era#a $iner, "iak *era%a iri un"uk ergaul karena
klien #ering ihina leh "e"anggan%a an klien #ering $en%eiri iru$ah, "iak 
 *era%a iri an $era#a $iner karena klien $era#a irin%a "iak erguna!

+a#alah (e*era.a"an : Harga iri renah

8! Huu
Huung
ngan
an ##i
##ial
al

a! Orang eka" : rang %ang

%ang eka" engan klien
klien %ai"u a*ak an
an Iun%a!
Iun%a!

 ! )eran #er"a ala$ kegia"an kel$*k / $a#%araka" : klien #ela$a #aki" "iak 
iku" kegia"an er$a#%araka"!

! Ha$a"an
Ha$a"an ala$ erhuungan
erhuungan engan
engan rang
rang lain
lain : i ru$ah
ru$ah #aki"
#aki" klien
klien jarang
jarang
 erk$unika#i engan "e$an%a an *era.a", klien "iak k*era"i klien #uka
ia$ an $en%eiri

+a#alah (e*era.a"an : i#la#i ##ial : $enarik iri

4! S*iri"ual

a! Nilai an ke%akinan

ke%akinan : klien erke%akinan
erke%akinan eraga$a
eraga$a i#la$!
i#la$!

 ! (egia"an iaah : klien #ela$ iru$ah #aki" ji.a "iak *ernah $elakukan
iaah

-! S"a"
S"a"u#
u# +en"
+en"al
al
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+a#alah ke*era.a"an : ei#i" (e*era.a"an iri

 ! )e$iaraan

klien $a#ih kaau an kaang "iak n%a$ung, "iak ku# an *elan!

+enarik iri : +enarik iri

! Ak"i
Ak"i?i
?i"a
"a## +"
+"ri
rik
k

(lien "a$*ak le#u, a*a" ergerak an erjalan engan ea# na$un gerakan
 *elan>*elan! Sela$a i Ru$ah Saki" klien un"uk $elakukan ak"i?i"a# #ehari>hari
#e*er"i $ani, $engg#k gigi, kera$a#, $akan an $engiku"i #ena$ na$un
haru# i $"i?a#i leh *era.a"!

! Ala$
Ala$ )era
)era##aan
aan

(lien $enga"akan *era#aann%a *aa hari ini #enang

e! Aek  

Aek
Aek (lien
(lien a"ar
a"ar #aa"
#aa" iajak
iajak eri
eriara
ara "en"an
"en"ang
g #eih
#eih an #enang
#enang "iak
"iak aa
 *eruahan r$an $uka, aa re#*n #aa" i.a.anara *anangan "iak $au
$eliha" %ang $engajak eriara, *anangan k#ng!

+a#alah (e*era.a"an : +enarik iri

! In"e
In"era
rak#
k#ii #ela
#ela$a
$a @a
@a.an
.anar
araa

Saa" .a.anara klien $au iajak k$unika#i, kn"ak $a"a kurang ku# / "iak 
ku#
ku# *aa
*aa la.an
la.an iara
iara,, klien
klien "iak
"iak $a$*u
$a$*u iajak
iajak iara
iara "erlal
"erlalu
u la$a
la$a an
 ia#an%a klien $in"a un"uk $enghinar a"au $egakhiri *eraka*an!

g! )er#e*#i
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h! )r#
)r#e#
e# *iki
*ikir 
r 

)aa #aa" .a.anara

.a.anara klien $a$*u $enja.a
$enja.a a*a %ang i"an%akan
i"an%akan leh *era.a"
*era.a"
na$un #e#ekali *er"an%aan %ang i erikan haru# i ulangi!

i! I#i )ikir  

Tiak "erjai gangguan i#i *ikir #e*er"i #e#i an .aha$!

 j! Tingka" (e#aaran

(lien "erkaang "a$*ak ingung, $enja.a *er"an%aan "iak kn#i#"en!

k! +e$ri

(lien $a$*u $enginga">inga" kegia"an>kegia"an %ang ilakukan iru$ah, Orang>

rang "ereka" an *aa #aa" ian"ar ke RS' r! A$in
A$in 3nHu"$!

l! Tingk
Tingka"
a" (n#
(n#en
en"r
"ra#
a#ii an erh
erhi"
i"un
ung
g

(e$a$*uan erhi"ung klien uku* aik, klien a*a" erkn#en"ra#i an $a$*u
 erhi"ung #eerhana! 7n"h $enghi"ung 1  10

$! (e$a$*u
(e$a$*uan
an *enila
*enilaian
ian

(lien
(lien $a$*u
$a$*u $enga$
$enga$il
il ke*u"u
ke*u"u#an
#an ian"a
ian"ara
ra ua hal,
hal, %ai"u
%ai"u #aa"
#aa" i"an%
i"an%aa $au
iaah a*a $ani uluB!(lien
uluB!(lien $enga"akan
$enga"akan $ani ulu agar ke"ika
ke"ika iaah klien
ala$ keaaan er#ih aru $akan!
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 ! A / A( 

(lien $enga"akan ia#an%a A 1; #ehari, A( kurang leih 4  -; #ehari!

(lien $enga"akan "iak aa keluhan ala$ *la A an A(!

! +ani

(lien $enga"akan $ani 2; #ela$a i RS', *agi *uku 06!00 an #re *ukul 16!00
@I!

! e*akaian

(lien "a$*ak er#ih, klien $enggunakan *akaian %ang i#eiakan leh RS' an
klien $a$*u erhia# #e*er"i er#i#ir an $e$"ng kuku!

e! (ee
(eerr#iha
#ihan
n ir
iri

(lien "a$*ak er#ih an er*ena$*ilan ra*i!

! I#"i
I#"ira
raha
ha"" an
an Tiur 
ur 

(lien $enga"akan *aa $ala$ hari "iur > ja$, #iang hari #eki"ar 1>2 ja$ "iur 
n%en%ak!

g! )eng
)enggu
guna
naan
an Oa"
Oa"

(lien $inu$ a" 2; *erhari!

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 j! (egia"an i luar ru$ah

(lien $enga"akan ah.a jarang $elakukan kegia"an iluar ru$ah!

! +eka
+ekani
ni#$
#$ee (*i
(*ing
ng

a! +a#a
+a#ala
lah
h engan
engan uku
ukung
ngan
an kel
kel$*
$*k 
k 

(lie "iak a*a" er##iali#a#i engan klien lain, keluarga $au*un *era.a"!

 ! +a#alah erhuungan engan lingkungan

(lien
(lien jarang
jarang ergau
ergaull an ha%a
ha%a $e$ili
$e$iliki
ki #eiki
#eiki"" "e$an,
"e$an, klien
klien leih
leih #uka
#uka
 eria$ i ala$ ru$ah!

! +a#a
+a#ala
lah
h enga
engan
n *en
*eni
iik
ikan
an

(lien $enga"akan ah.a irin%a kee.a han%a #e$*a" #eklah #a$*ai S+)
an klien "iak a*a" $elanju"kan #eklah lagi karena $a#alah ia%a!

! +a#a
+a#ala
lah
h en
engan
gan *eker
*ekerja
jan
n

(lien
(lien ulu
ulu *ernah
*ernah ekerja
ekerja i "k
"k "e"a*i
"e"a*i klien
klien keluar
keluar karena "iak e"ah
engan "e$*a" kerjan%a an #uka ihina "e$an>"e$an%a!

e! +a#a
+a#ala
lah
h en
engan
gan *eru
*eru$a
$aha
han
n

(lien $engangga* "e"anggan%a "iak $en%ukain%a an $e%e*elekan irin%a

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! )enge"
ge"ahuan

(lien "iak $ege"ahui "en"ang ara $enga"a#i $a#alah %ang ihaa*i C $a#alah
ei#i" *era.a"an iri erhia# $e$"ng kukuD "iak $enge"ahui ila #e"elah $ani
akan "era#a n%a$an an #egar na$un klien $era#a $ala#
$ala# un"uk $elakuan *era.a"an
iri!

E+a#alah (e*era.a"an : ei#i" )era.a"an iri

! A#*ek
*ek +ei#

iagn#a +ei# : SkiGernia

Tera*i $ei#

1! Trihak#i*heniil 8; 2 $g

2! iGa*
iGa*in
in 2; 12,- $g

8! (al;ein 1; 20 g

10! +a#alah (e*era.a"an

1! ei#i" *era.a"an iri

2! Harga iri renah

8! I#la#i ##ial
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ANAISA
ANAIS A DATA
DATA

 N! Hari/Tanggal
Hari/Tanggal a"a Fku# +a#alah )ara 
1! Sela#a,10juni S : klien $enga"akan I#la#i S#ial :
2014 iru
iru$a
$ah
h #aki
#aki"" klie
klien
n jara
jarang
ng +enarik iri
 erk$unika#i engan
"e$a
"e$an%
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Tujuan (ri"eria e?alua#i

ei#i"
ei#i" )era.a"an
)era.a"an Tujuan u$u$ : (lien
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10:1- klien #uka $en%eniri i ka$arn%a!

ka$arn%a!
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k*era"i "iak aa  
kn"ak $a"a *anangan
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engan *era.a" an
"e$an>"e$an%a!
iagn#a (e*era.a"an :
ei#i" (e*era.a"an iri
O : klien "iak k*era"i
"iak aa kn"ak $a"a
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"e$an>"e$an%a!
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huungan #aling *era%a
engan *era.a" an "e$an>
"e$an%a!
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• engar ungka*an
 *era#aan klien

• )enuhi keu"uhan
a#ar *a#ien

S : klien $enga"akan jika

#: klien $enga"akan
$au $ani haru# i#uruh
Rau 11 juni  jika $au $ani haru#
ulu leh *era.a"!
2014 i#uruh ulu leh
 *era.a", klien O : #aa" i r# *a#ien $a$*u
0:00
$enga"akan $akan haru# $elakukan ara>ara

i#uruh leh *era.a"  *era.a"an iri %ang aik

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ka$ar $ani, $ani  er#ih, $a$*u $elakukan

$enggunakan #aun  
$ani, g#k ii, gan"i
 aju #e"elah #ele#ai
$anian kera$a#
$enggunakan #ha$*!
 : klien "erliha"
$a$*u $elakukan ara
 *era.a"n iri engan
 aik an enar!
iagn#a (e*era.a"an :
*era.a"an iri %ai"u :
• +ani 2; #ehari
$enggunakan #aun
• 3#k gigi #ehai#
$akan
• (era$a# 2 hari
#ekali
• 3an"i *akaian #e"ia*
#ele#ai $ani !

ei#i" )era.a"an iri

• erhia# #e"elah

Tinakan S*2 $ani

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