FORMAT PENGKAJIAN KEPERAWATAN JIWA

Ruang Rawat : Tanggal Dirawat:

A. Identitas Klien.
Nama (Inisial) : _______________________________________________
Umur : _______________________________________________
Jenis Kelamin : _______________________________________________
Suku Bangsa : _______________________________________________
Agama : _______________________________________________
Status Perkawinan : _______________________________________________
Pekerjaan : _______________________________________________
Alamat : _______________________________________________
Tanggal Masuk : _______________________________________________
Tanggal Pengkajian : _______________________________________________
No CM : _______________________________________________
Diagnosa Medis : _______________________________________________

Penanggungjawab Klien : _______________________________________________

B. Alasan Masuk:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

C. Faktor Predisposisi:
1. Pernah mengalami gangguan jiwa di masa lalu : Ya Tidak
2. Pengobatan sebelumnya :
Berhasil Kurang Berhasil Tidak Berhasil

3. a. Aniaya Fisik : Pelaku/Usia Korban/Usia Saksi/Usia

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 1
 b. Aniaya Seksual : Pelaku/Usia Korban/Usia Saksi/Usia

c. Penolakan : Pelaku/Usia Korban/Usia Saksi/Usia

d. Kekerasan dalam Keluarga : Pelaku/Usia Korban/Usia Saksi/Usia

e. Tindakan Kriminal : Pelaku/Usia Korban/Usia Saksi/Usia

Jelaskan No. 1, 2 dan 3 :

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

4. Ada anggota keluarga yang mengalami gangguan jiwa : Ya Tidak

Hubungan Keluarga Gejala Riwayat Pengobatan/Perawatan

Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

5. Pengalaman masa lalu yang tidak menyenangkan:

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 2
 Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

D. Pemeriksaan Fisik.
1. Tanda-tanda Vital : TD : .............. mmHg, N : ....... x/menit. RR : ......... x/menit.
2. TB : ................. Cm BB : ........... Kg IMT : ..............
3. Keluhan Fisik : Ya Tidak

Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

E. Psikososial.
1. Genogram.

Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

2. Konsep Diri.
a. Gambaran Diri.
________________________________________________________________
________________________________________________________________
________________________________________________________________

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 3
 b. Identitas Diri.
________________________________________________________________
________________________________________________________________
________________________________________________________________
c. Peran Diri.
________________________________________________________________
________________________________________________________________
________________________________________________________________
d. Ideal Diri.
________________________________________________________________
________________________________________________________________
________________________________________________________________
e. Harga Diri.
________________________________________________________________
________________________________________________________________
________________________________________________________________

Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

3. Hubungan Sosial.
a. Orang yang berarti:
________________________________________________________________
________________________________________________________________
b. Peran serta dalam kegiatan kelompok/masyarakat:
________________________________________________________________
________________________________________________________________
c. Hambatan dalam berhubungan dengan orang lain:
________________________________________________________________
________________________________________________________________

Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 4
 4. Spritual.
a. Nilai dan Keyakinan.
________________________________________________________________
________________________________________________________________
________________________________________________________________
b. Kegiatan Ibadah.
________________________________________________________________
________________________________________________________________
________________________________________________________________

Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

F. Status Mental.
1. Penampilan.
Tidak rapi.
Penggunaan pakaian tidak sesuai.
Cara berpakaian tidak seperti biasanya.
Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

2. Pembicaraan.
Cepat Keras Gelisah Inkoheren
Apatis Lambat Membisu
Tidak mampu memulai pembicaraan.
Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 5
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

3. Aktivitas Motorik.
Lesu Tegang Gelisah/Agitasi
Tik Grimasen. Tremor Kompulsif.
Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

4. Alam Perasaan.
Sedih Ketakutan Putus asa Khawatir
Gembira berlebihan.
Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

5. Afek.
Datar Tumpul Labil Tidak Sesuai
Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 6
6. Interaksi Selama Wawancara.
Bermusuhan Tidak Kooperatif Mudah Tersinggung.
Kontak Mata (–) Defensif. Curiga.
Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

7. Persepsi.
Pendengaran Penglihatan Perabaan
Pengecapan Penghidu
Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

8. Proses Pikir.
Sirkumtansial Tangensial Kehilangan Asosiasi
Flight of Idea Blocking
Pengulangan Pembicacaraan/Preseverasi

Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 7
 9. Isi Pikir.
Obsesi Fobia Hipokondria
Depersonalisasi Ide Yang Terkait Pikiran Magis
Waham:
Agama Somatik Kebesaran Curiga.
Nihilistik Sisip Pikir Siar Pikir Kontrol Pikir.
Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

10. Tingkat Kesadaran.

Bingung Sedasi Stupor
Disorientasi:
Waktu Tempat Orang

Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

11. Memori.
Gangguan Daya Ingat Jangka Panjang
Gangguan Daya Ingat Jangka Pendek.
Gangguan Daya Ingat Saat Ini.
Konfabulasi.
Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 8
 Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

12. Tingkat Konsentrasi dan Berhitung.

Mudah Beralih Tidak Mampu Konsentrasi
Tidak Mampu Berhitung Sederhana.

Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

13. Kemampuan Penilaian.

Gangguan Ringan Gangguan Bermakna

Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

14. Daya Tilik Diri.

Mengingkari Penyakit Yang Diderita
Menyalahkan Hal-hal Diluar Dirinya.

Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 9
G. Kebutuhan Persiapan Pulang.
1. Makan : Bantuan Minimal Bantuan Total
2. BAB / BAK : Bantuan Minimal Bantuan Total
Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

3. Mandi : Bantuan Minimal Bantuan Total

4. Berpakaian / Berhias : Bantuan Minimal Bantuan Total
5. Istirahat dan Tidur : Tidur Siang, Lama : ..................... s.d ......................
Tidur Malam, Lama : ..................... s.d ......................

6. Penggunaan Obat : Bantuan Minimal Bantuan Total

7. Pemeliharaan Kesehatan.
Perawatan Lanjutan : Ya Tidak
Perawatan Pendukung : Ya Tidak
8. Kegiatan Didalam Rumah.
Mempersiapkan Makanan : Ya Tidak
Menjaga Kerapihan Rumah : Ya Tidak
Mencuci Pakaian : Ya Tidak
Pengaturan Keuangan : Ya Tidak
9. Kegiatan Diluar Rumah.
Belanja : Ya Tidak
Transportasi : Ya Tidak
Lain-lain : Ya Tidak

Jelaskan:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 10
H. Mekanisme Koping.
Adaptif Maladaptif
Bicara dengan orang lain Minum alkohol
Mampu menyelesaikan masalah Reaksi lambat/berlebih
Teknik relaksasi Bekerja berlebihan
Aktivitas konstruktif Menghindar.
Olahraga Menciderai diri
Laninya: ........................................... Lainnya: ..................................

Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

I. Masalah Psikososial dan Lingkungan.

1. Masalah dengan dukungan kelompok, spesifik :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
2. Masalah berhunbungan dengan lingkungan, spesifik :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
3. Masalah dengan pendikan, spesifik :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
4. Masalah dengan pekerjaan, spesifik :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
5. Masalah dengan perumahan, spesifik :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
6. Masalah dengan ekonomi, spesfik :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 11
 7. Masalah dengan pelayanan kesehatan, spesifik :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
8. Masalah lainnya, spesifik :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

J. Pengetahuan Kurang Tentang:

Penyakit jiwa. Sistem pendunkung
Faktor presipitasi Penyakit fisik
Koping Obat-obatan
Laninya: ...................................................................................................................

Masalah Keperawatan :
_____________________________________________________________________
_____________________________________________________________________

K. Aspek Medik.
Diagnosa Medik:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Terapi Medik:
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 12
 ANALISA DATA
Data Masalah
Tanggal Tandatangan
(Subyektif dan Obyektif) Keperawatan

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 13
L. Pohon Masalah (Pohon Diagnosa).

Effect

Core Problem

Cause

M. Daftar Masalah Keperawatan.

1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
5. ___________________________________________________________________

N. Daftar Diagnosa Keperawatan Berdasarkan Prioritas.

1. ___________________________________________________________________
___________________________________________________________________
2. ___________________________________________________________________
___________________________________________________________________
3. ___________________________________________________________________
___________________________________________________________________
4. ___________________________________________________________________
___________________________________________________________________
5. ___________________________________________________________________
___________________________________________________________________

....................................., ......, ....................., .............

Masiswa

( ________________________________ )
NIM :

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 14
 RENCANA ASUHAN KEPERAWATAN JIWA

Nama Klien (Initial) : ______________________ Nama Mahasiswa : ______________________

No. RM : ______________________ Institusi / Ruangan : ______________________
PERENCANAAN
DIAGNOSA
NO TANGGAL TINDAKAN RASIONAL
KEPERAWATAN TUJUAN KRITERIA HASIL
KEPERAWATAN

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 15
 CATATAN PERKEMBANGAN KEPERAWATAN JIWA

Nama Klien (Initial) : ______________________ Nama Mahasiswa : ______________________

No. RM : ______________________ Institusi / Ruangan : ______________________
HARI /
DIAGNOSA TANDA
TANGGAL / IMPLEMENTASI KEPERAWATAN EVALUASI (S O A P)
KEPERAWATAN TANGAN
PUKUL

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 16
 FORMAT ANALISA PROSES INTERAKSI

Nama Mahasiswa : _________________________________ Nama (initial) Klien : ____________________________________

Tanggal & Waktu : _________________________________ Tempat : ____________________________________
Interaksi Ke : _________________________________ Lingkungan : ____________________________________
Deskripsi Klien : _________________________________ Tujuan : ____________________________________

KOMUNIKASI VERBAL KOMUNIKASI ANALISA BERPUSAT ANALISA BERPUSAT RASIONAL

NONVERBAL PADA PERAWAT PADA KLIEN
P: P: P: P:

K: K: K: K:

P: P: P: P:

K: K: K: K:

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 17
 FORMAT RENCANA HARIAN PRAKTIK

Hari dan Tanggal : ________________________ Nama Klien (initial): _____________

Ruangan : ________________________
TIDAK
WAKTU KEGIATAN DIKERJAKAN KETERANGAN
DIKERJAKAN

................................., ......., ..............., ............

Pembimbing

( __________________________________ )

Fomat Asuhan Keperawatan Jiwa Program Studi Profesi Ners Stikes Hang Tuah Tanjungpinang| 18