FORMULIR PENGKAJIANKEPERAWATAN KESEHATAN JIWA

RUANGAN RAWAT ____________TANGGAL DIRAWAT ______________

I. IDENTITAS KLIEN
Inisial
: _________________ (L/P)
Tanggal pengkajian : _________________
Umur
: _________________
RM No.
: _________________
Informan
: _________________
II. ALASAN MASUK
________________________________________________________________
________________________________________________________________
________________________________________________________________
III. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu :Ya [ ]
2. Pengobatan sebelumnya
3.

:Berhasil [ ]

Tidak [ ]

Kurang berhasil [ ]

Pelaku/Usia

Korban/Usia

Saksi/Usia

Aniaya fisik

][

][

][

Aniaya seksual

][

][

][

Penolakan

][

][

][

Kekerasan di keluarga

][

][

][

Tindakan kriminal

][

][

][

Jelaskan No. 1, 2, 3
:
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Masalah Keperawatan
_____________________________________________________________
_____________________________________________________________

4. Adakah anggota keluarga yang mengalami gangguan jiwa:Ya [ ] Tidak [ ]

Hubungan keluarga
: ________________________________
Gejala
: ________________________________
Riwayat pengobatan/perawaran
: ________________________________
Masalah Keperawatan:
______________________________________________________________
______________________________________________________________
5. Pengalaman masa lalu yang tidak menyenangkan
_______________________________________________________________
______________________________________________________________
Masalah Keperawatan:
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IV.FISIK
1. Tanda vital
: TD : ________N : _______S : _______ P : ______
2. Ukur
: TB : __________ BB : ________
3. Keluhan fisik
: Ya [ ]
Tidak [ ]
Jelaskan
:
________________________________________________________________
Masalah keperawatan :
________________________________________________________________
________________________________________________________________
V. PSIKOSOSIAL
1. Genogram

Jelaskan
:
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Masalah Keperawatan
:
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2. Konsep diri
a.Gambaran diri :
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b. Identitas
:
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c. Peran
:
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d. Ideal diri
:
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e. Harga diri
:
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Masalah Keperawatan :
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3. Hubungan Sosial
a. Orang yang berarti :
_______________________________________________________________
b. Peran serta dalam kegiatan kelompok / masyarakat :
_______________________________________________________________
_______________________________________________________________
c. Hambatan dalam berbuhungan dengan orang lain :
_______________________________________________________________
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Masalah keperawatan:
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4. Spiritual
a. Nilai dan keyakinan :
_______________________________________________________________
b. Kegiatan ibadah
:
______________________________________________________________
Masalah Keperawatan :
_______________________________________________________________
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VI. STATUS MENTAL

1. Penampilan
Tidak rapi [ ] Penggunaan pakaian tidak sesuai [ ]
Cara berpakaian tidak sesuai [ ]
Jelaskan :
______________________________________________________________
______________________________________________________________
Masalah Keperawatan :
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2. Pembicaraan
Cepat [ ]
Keras [ ]
Gagap [ ]
Inkoheren [ ]
Apatis [ ]
Lambat [ ]
Membisu [ ]
Tidak mampu memulai pembicaraan [ ]
Jelaskan :
______________________________________________________________
______________________________________________________________
Masalah Keperawatan :
______________________________________________________________
______________________________________________________________
3. Aktivitas Motorik:
Lesu [ ]
Tegang [ ]
Tik [ ]

Grimasen [ ]

Gelisah [ ]

Agitasi [ ]

Tremor [ ]

Kompulsif [ ]

Jelaskan :
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Masalah Keperawatan :
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4. Alam perasaaan
Sedih [ ] Ketakutan [ ] Putus asa [ ] Khawatir [ ] Euforia [ ]
Jelaskan :
______________________________________________________________
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Masalah Keperawatan:
______________________________________________________________
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5. Afek
Datar [ ]

Tumpul [ ]

Labil [ ]

Tidak sesuai [ ]

Jelaskan :
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Masalah Keperawatan :
______________________________________________________________
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6. lnteraksi selama wawancara
Bermusuhan [ ]
Tidak kooperatif [ ]
Kontak mata (-) [ ] Defensif [ ]

Mudah tersinggung [ ]
Curiga [ ]

Jelaskan :
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Masalah Keperawatan :
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7. Persepsi
Pendengaran [ ]
Penglihatan [ ]
Perabaan [ ]
Pengecapan [ ]
Penghidu [ ]
Jelaskan :
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Masalah Keperawatan :
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8. Proses Pikir
Sirkumtansial [ ]
Flight of idea [ ]

Tangensial [ ]
Blocking [ ]

Kehilangan asosiasi [ ]
Persevarasi [ ]

Jelaskan :
______________________________________________________________
______________________________________________________________
Masalah Keperawatan :
______________________________________________________________
______________________________________________________________
9. Isi Pikir
Obsesi [ ]
Depersonalisasi [ ]
Waham
Agama [ ]
Nihilistic [ ]

Fobia [ ]
Ide yang terkait [ ]

Somatik [ ]
Sisip pikir [ ]

Hipokondria [ ]
Pikiran magis [ ]

Kebesaran [ ]
Siar pikir [ ]

Curiga [ ]
Kontrol pikir [ ]

Jelaskan:
______________________________________________________________
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Masalah Keperawatan:
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10. Tingkat kesadaran
Bingung [ ]
Disorientasi:
Waktu [ ]

Sedasi [ ]

Stupor [ ]

Tempat [ ]

Orang [ ]

Jelaskan:
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Masalah Keperawatan:
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11. Memori
Gangguan memori jangka panjang [ ] Gangguan memori jangka pendek [ ]
Gangguan daya ingat saat ini [ ]
Konfabulasi [ ]
Jelaskan:
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Masalah Keperawatan:
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12. Tingkat konsentrasi dan berhitung
Mudah beralih [ ]
Tidak mampu konsentrasi [ ]
Tidak mampu berhitung sederhana [ ]
Jelaskan:
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Masalah Keperawatan:
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13. Kemampuan penilaian
Gangguan ringan [ ]

Gangguan bermakna [ ]

Jelaskan:
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Masalah Keperawatan:
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14. Daya tilik diri

Mengingkari penyakit yang diderita [ ]
Menyalahkan hal-hal diluar dirinya [ ]
Jelaskan:
______________________________________________________________
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Masalah Keperawatan:
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VII. Kebutuhan Persiapan Pulang
1. Makan
Bantuan minimal [ ]

Bantuan total [ ]

2. BAB/BAK
Bantuan minimal [ ]

Bantual total [ ]

Jelaskan:
_______________________________________________________________
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Masalah Keperawatan:
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3. Mandi
Bantuan minimal [ ]

Bantuan total [ ]

4. Berpakaian/berhias
Bantuan minimal [ ]

Bantual total [ ]

5. Istirahat dan tidur

Tidur siang lama
: .s/d
Tidur malam lama : s/d
Kegiatan sebelum / sesudah tidur: __________________________________
6. Penggunaan obat
Bantuan minimal [ ]

Bantual total [ ]

7. Pemeliharaan Kesehatan
Perawatan lanjutan
:
Perawatan pendukung :

Ya [ ]
Ya [ ]

Tidak [ ]
Tidak [ ]

Tidak [
Tidak [
Tidak [
Tidak [

8. Kegiatan di dalam rumah

Mempersiapkan makanan
Menjaga kerapihan rumah
Mencuci pakaian
Pengaturan keuangan

:
:
:
:

Ya [
Ya [
Ya [
Ya [

9. Kegiatan di luar rumah

Belanja
Transportasi
Lain-lain

:
:
:

Ya [ ]
Ya [ ]
Ya [ ]

]
]
]
]

]
]
]
]

Tidak [ ]
Tidak [ ]
Tidak [ ]

Jelaskan:
______________________________________________________________
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Masalah Keperawatan:
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______________________________________________________________

VIII. Mekanisme Koping

Adaptif

Maladaptif

Bicara dengan orang lain [ ]

Minum alkohol [ ]
Mampu menyelesaikan masalah [ ]
Reaksi lambat/berlebih [ ]
Teknik relaksasi [ ]
Bekerja berlebihan [ ]
Aktivitas konstruktif [ ]
Menghindar [ ]
Olahraga [ ]
Mencederai diri [ ]
Lainnya _______________________________________________________
Masalah Keperawatan:
______________________________________________________________
______________________________________________________________

IX. Masalah Psikososial dan Lingkungan:

[ ] Masalah dengan dukungan kelompok, spesifik
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[ ] Masalah berhubungan dengan lingkungan, spesifik
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[ ] Masalah dengan pendidikan, spesifik
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[ ] Masalah dengan pekerjaan, spesifik
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[ ] Masalah dengan perumahan, spesifik
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[ ] Masalah ekonomi, spesifik
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[ ] Masalah dengan pelayanan kesehatan, spesifik
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________________________________________________________________
[ ] Masalah lainnya, spesifik
________________________________________________________________
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Masalah Keperawatan:
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X. Pengetahuan Kurang Tentang:

[ ] Penyakit jiwa
[ ] System pendukung
[ ] Faktor presipitasi
[ ] Penyakit fisik
[ ] Koping
[ ] Obat-obatan
Lainnya:
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Masalah Keperawatan:
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Analisa Data
Data
Subjektif
..........................................................
..........................................................
Objektif
...
...
Subjektif
..........................................................
..........................................................
Objektif
...
...

Masalah
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.

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.

XI. Aspek Medik

Diagnosa Medik:
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Terapi Medik :
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XII. Daftar Masalah Keperawatan dan pohon masalah

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XIII. Daftar Diagnosis Keperawatan

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_____________,______________
Mahasiswa,
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