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PENGKAJIAN KEPERAWATAN
KESEHATAN JIWA
Tanggal MRS : ………………..
Tanggal Dirawat di Ruangan :
………………..
Tanggal Pengkajian : ……………........
Ruang Rawat : …………………
I. IDENTITAS KLIEN
Nama : …………………….. (L/P)
Umur : …………….. ………
:
Alamat
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Pendidikan :
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:
Agama
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:
Status
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:
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Pekerjaan
:
JenisKel.
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No CM
:
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II. ALASAN MASUK
a. DataPrimer
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b. DataSekunder
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c. Keluhan Utama Saat Pengkajian
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III. RIWAYAT PENYAKIT SEKARANG (FAKTOR PRESIPITASI)
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IV. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)
1. Pernah mengalami gangguan jiwa di masa lalu ?
Ya
Tidak
JikaYa,Jelaskan kapan, tanda gejala/keluhan :
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2. Faktor Penyebab/Pendukung :
a. Riwayat Trauma
Usia Pelaku Korban Saksi
1. Aniayafisik ………… ………… ………… …………
2. Aniayaseksual ………… ………… ………… …………
3. Penolakan ………… ………… ………… …………
4. Kekerasan dalam keluarga ………… ………… ………… …………
5. Tindakan kriminal ………… ………… ………… …………
Jelaskan:
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DiagnosaKeperawatan :
b. Pernah melakukan upaya / percobaan / bunuh diri
Jelaskan:
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DiagnosaKeperawatan :
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c. Pengalaman masalalu yang tidak menyenangkan (peristiwa kegagalan, kematian,
perpisahan )
Jika ada jelaskan :
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DiagnosaKeperawatan :
d. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
Ya
Tidak
Jika yaJelaskan
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Diagnosa Keperawatan :
e. Riwayat Penggunaan NAPZA
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Diagnosa Keperawatan :
3. Upaya yang telah dilakukan terkait kondisi di atas dan hasilnya :
Jelaskan :
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Diagnosa Keperawatan :
4. Riwayat Penyakit Keluarga
Anggotakeluarga yang gangguanjiwa ?
Ada
Tidak
Jika ada :
Hubungankeluarga :
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Gejala :
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Riwayat pengobatan :
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Diagnosa Keperawatan :
V. PENGKAJIAN PSIKOSOSIAL (Sebelum dan sesudah sakit)
1. Genogram:
Jelaskan:
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Diagnosa Keperawatan :
2. Konsep Diri
a. Citra tubuh :
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b. Identitas :
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c. Peran :
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d. Ideal diri :
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e. Hargadiri :
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Diagnosa Keperawatan :
3. Hubungan Sosial
a. Orang yang berarti/terdekat
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b. Peran serta dalam kegiatan kelompok/masyarakat dan hubungan sosial
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c. Hambatandalamberhubungandengan orang lain
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Diagnosa Keperawatan :
4. Spiritual
a. Agama
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b. Pandangan terhadap gangguan jiwa
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Diagnosa Keperawatan:
VI. PEMERIKSAAAN FISIK
1. Keadaan umum
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2. Kesadaran (Kuantitas)
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3. Tanda vital:
TD : ……. mm/Hg
N
:…….. x/menit
S
: …….. CO
P : ……..
x/menit
4. Ukur:
BB : ……. Kg
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TB : ……. Cm
5. Keluhan fisik:
Jelaskan :
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Diagnosa Keperawatan :
VII.STATUS MENTAL
1. Penampilan (Penanpilan usia, cara perpakaian, kebersihan)
Jelaskan:
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Diagnosa Keperawatan:
2. Pembicaraan (Frekuensi, Volume, Jumlah, Karakter) :
Jelaskan:
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Diagnosa Keperawatan:
3. Aktifitasmotorik/Psikomotor
Kelambatan :
Hipokinesia,hipoaktifitas
Katalepsi
Sub stupor katatonik
Fleksibilitas serea
Jelaskan:
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Peningkatan :
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Hiperkinesia,hiperaktifita Grimace
s Otomatisma
Stereotipi Negativisme
Gaduh Gelisah Katatonik Reaksikonversi
Mannarism Tremor
Katapleksi Verbigerasi
Tik Berjalankaku/rigid
Ekhopraxia Kompulsif :sebutkan
Command automatism …………
Jelaskan:
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Diagnosa Keperawatan :
4. Mood dan Afek
a. Mood
Depresi Khawatir
Ketakutan Anhedonia
Euforia Kesepian
Lain lain
Jelaskan
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b. Afek
Sesuai Tidak sesuai
Tumpul/dangkal/datar Labil
Jelaskan:
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Diagnosa Keperawatan
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5. Interaksi Selama Wawancara
Bermusuhan Kontak mata kurang
Tidak kooperatif Defensif
Mudah tersinggung Curiga
Jelaskan:
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Diagnosa Keperawatan
6. Persepsi Sensorik
a. Halusinasi
Pendengaran
Penglihatan
Perabaan
Pengecapan
Penciuman
b. Ilusi
Ada
Tidakada
Jelaskan:
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Diagnosa Keperawatan
7. Proses Pikir
a. ArusPikir:
Koheren Inkoheren
Sirkumtansial Asosiai longgar
tangensial Flight of Idea
Blocking Perseverasi
Logorhoe Neologisme
Clang Association Main kata kata
Afasia Lain lain…
Jelaskan:
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b. Isi Pikir
Fobia,sebutkan………….
Obsesif
.
Ekstasi Waham:
Fantasi o Agama
Alienasi o Somatik/hipokondria
Pikiran bunuh diri o Kebesaran
Preokupasi o Kejar / curiga
Pikiran isolasisosial o Nihilistik
Ide yang terkait o Dosa
PikiranRendahdiri o Sisip pikir
Pesimisme o Siar piker
Pikiran magis o Kontrol pikir
Pikiran curiga Lain lain :
Jelaskan:
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c. Bentuk pikir :
Realistik
Non realistik
Dereistik
Otistik
Jelaskan:
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Diagnosa Keperawatan:
8. Kesadaran
Orientasi (waktu, tempat, orang)
Jelaskan:
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Meninggi
Menurun:
Kesadaran berubah
Hipnosa
Confusion
Sedasi
Stupor
Jelaskan:
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Diagnosa Keperawatan:
9. Memori
Gangguan daya ingat jangka panjang ( > 1 bulan)
Gangguan dayaingat jangka menengah ( 24 jam - ≤ 1 bulan)
Gangguan daya ingat pendek (kurun waktu 10 detik sampai 15 menit)
Jelaskan:
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Diagnosa Keperawatan:
10. Tingkat Konsentrasi dan Berhitung
a. Konsentrasi
Mudah beralih
Tidak mampu berkonsentrasi
Jelaskan:
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b. Berhitung
Jelaskan:
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Diagnosa Keperawatan:
11. Kemampuan Penilaian
Gangguan ringan
Gangguan bermakna
Jelaskan :
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Diagnosa Keperawatan:
12. Daya Tilik Diri
Mengingkari penyakit yang diderita
Menyalah kanhal-hal diluar dirinya
Jelaskan:
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Diagnosa Keperawatan:
VIII. KEBUTUHAN PERSIAPAN PULANG
1. Kemampuan klien memenuhi kebutuhan
perawatan kesehatan,
transportasi,
tempat tinggal.
Keuangan dan kebutuhan lainnya.
Jelaskan:
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2. Kegiatan Hidup Sehari hari
a. Perawatan diri
1) Mandi
Jelaskan :
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2) Berpakaian, berhias dan berdandan
Jelaskan :
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3) Makan
Jelaskan :
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4) Toileting (BAK, BAB)
Jelaskan :
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Diagnosa Keperawatan:
b. Nutrisi
Berapa frekwensi makan dan frekwensi kudapan dalam sehari.
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Bagaimana nafsu makannya
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Bagaimana berat badannya.
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Diagnosa Keperawatan:
c. Tidur
1) Istirahat dan tidur
Tidur siang, lama : ____________ s/d _____________
Tidur malam, lama : _____________ s/d _____________
Aktifitas sebelum/sesudah tidur : __________ , _________
Jelaskan
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2) Gangguan tidur
Insomnia
Hipersomnia
Parasomnia
Lain lain
Jelaskan
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Diagnosa Keperawatan:
3. Kemampuan lain lain
Mengantisipasi kebutuhan hidup
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Membuat keputusan berdasarkan keinginannya,
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Mengatur penggunaan obat dan melakukan pemeriksaan kesehatannya sendiri.
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Diagnosa Keperawatan:
4. Sistem Pendukung Ya Tidak
Keluarga 
Terapis
Teman sejawat
Kelompok sosial
Jelaskan :
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Diagnosa Keperawatan:
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IX. MEKANISME KOPING
Jelaskan :
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Diagnosa Keperawatan:
X. MASALAH PSIKOSOSIALDAN LINGKUNGAN
Masalah dengan dukungan kelompok, spesifiknya
Jelaskan :
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Masalah berhubungan dengan lingkungan, spesifiknya
Jelaskan :
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Masalah dengan pendidikan, spesifiknya
Jelaskan :
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Masalah dengan pekerjaan, spesifiknya
Jelaskan :
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Masalah dengan perumahan, spesifiknya
Jelaskan :
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Masalah dengan ekonomi, spesifiknya
Jelaskan :
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Masalah dengan pelayanan kesehatan, spesifiknya
Jelaskan :
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Masalah lainnya, spesifiknya
Jelaskan :
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Diagnosa Keperawatan:
XI. ASPEK PENGETAHUAN
Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang kurang
tentang suatu hal?
Bagaimana pengetahuan klien/keluarga saat ini tentang penyakit / gangguan jiwa,
perawatan dan penatalaksanaanya faktor yang memperberat masalah (presipitasi), obatobatan
atau lainnya. Apakah perlu diberikan tambahan pengetahuan yang berkaitan
dengan spesifiknya masalah tsb
Penyakit/gangguan jiwa Penatalaksanaan
Sistem pendukung Lain-lain, jelaskan
Faktor presipitasi
Jelaskan :
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Diagnosa Keperawatan:
XII. ASPEK MEDIS
1. Diagnosis Multi Axis
Axis I : .........................................................................................................................
Axis II : ........................................................................................................................
Axis III : .........................................................................................................................
Axis IV :.........................................................................................................................
Axis V : ........................................................................................................................
2. Terapi Medis
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XIII. ANALISA DATA
DIAGNOSA
N
DATA KEPERAWAT
O
AN
DS:
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1.
DO:
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DS:
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2.
DO:
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DS:
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3.
DO:
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DS:
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4.
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DO:
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DS:
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ds ..........................
t DO:
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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, ……………………….
Perawat yang mengkaji
____________________
NIM/NIRM: ..………….
1
TINDAKAN KEPERAWATAN JIWA
Nama : Ruang :
No CM : Unit :
Tanggal Diagnosa
No Tindakan Kepera
Jam Keperawatan

1
Keterangan :
Cara pendoku mentasian :
Mengacu pada fasefase komunikasi terapeutik
Pada kolom waktu diisi : Dx. Kep, Tanggal & jam tindakan
Pada kolom Tindakan Keperawatan diisi :
Fase Oreantasi : Saat evaluasi/ validasi
Fasekerja : Sesuai tindakan fase kerja
Fase terminasi: Rencana Tindak Lanjut
KolomEvaluasi:
Evaluasi subyektif & Obyektif
Berdasarkan respon subyektif, evaluasi obyektif
Sesuai hasil evaluasi respon subyektif & obyektif pada fase terminasi
A : Analisa , Sesuai dengan hasilin teraksi terakhir
P : Planning , terdiridari P pasien dan P perawat
P pasien : berdasarkan hasil rencana tindak lanjut pada fase terminasi
P perawat : berdasarkan hasil kontrak yang akan datang pada fase
terminasi