PENGKAJIAN

MASALAH PASIEN

Sri Padma Sari

 TUJUAN
 Identifikasi
klien
 Pengkajian psikososial
YANG MEMBUTUHKAN KONSELING
 Konflik intrapsikis: indikatornya kecemasan,
sulit konsentrasi, depresi dan motivasi rendah
 Ketidaksesuaian antara stimulus dan respon
(pasif)
 Pola pikir irasional (merugikan diri sendiri)

 Tidak sesuai antara ideal self dengan real self

Purpose of Assessment

 Assessment is the process whereby counselors collect data that

helps the counselor make decisions about the client. Assessment
is used to:

 Diagnose client problems.

 Make predictions about clients.

 Developing client self-awareness.

Types of Assessment

 Standardized Tests: An objective measure given in a standard

way.

 Nonstandardized Assessment or Clinical Assessment: This is the

counselor’s assessment of an individual based on clinical
experience.
Types of Standardized Tests

 Intelligence Tests (General mental ability).

 Aptitude Tests (Knowledge and skills useful in educational or
vocational settings).
 Achievement Tests (Skills and knowledge acquired through
education).
 Career-related Inventories (Looks at preferences and beliefs
about career).
 Personality Inventories (Looks at consistent patterns of thoughts
and behaviors).
Assessment Through Interviews

 The Intake Interview: Addresses client problems and resources in

preparation for treatment or referral.

 What is the client's presenting problem?

 What is the history of the problem?

 What has been the treatment of the problem?

 Are there any other problems?

 What is the client’s social, educational and occupational

history?
 What is the client’s medical history?

 What are the client's resources and abilities?

Assessment Through Interviews (continued)

 Making A Diagnosis: Usually in a mental health setting using the

DSM-IV.

 Diagnosis should be about the client’s current problem.

 Past history can confirm or rule out a diagnosis.

 Intensity and frequency of the problem is important to note.

 Has the client deteriorated as a result of the problem?

 What has been the duration of the problem?

 Pengkajian psikososial

Kesejahteraan emosi klien

Assessment ???
Kesejahteraan emosi saat ini

 Cek adanya gejala cemas dan depresi (kesedihan,

stress)
 Melalui perubahan makan dan tidur
 Catatan adanya:
- Perubahan penampilan
- Perhatian dan konsentrasi
- Mood
- Afek

- Apakah anda mengalami perubahan dalam makan,

tidur?
- Apakah anda sedang merasa cemas atau memikirkan
sesuatu?
 Mental Status Exam

Counselors can use the mental status

exam to get a clearer picture of what is
going on with the client and to make a
differential diagnosis.

Purpose: observe symptoms of mental impairment

in a controlled, interpersonal setting.
MENTAL STATUS EXAMINATIONS

 Appearance.  Perceptions.
 Behavior.  Orientation (person,
 Mood & Affect. place, time).
 Attitude toward
 Memory.
examination.
 Judgment.
 Speech/language.
 Cognition.  Insight.

 Intellectual
Functioning.
 Riwayat kesehatan mental

riwayat ke psikolog, dokter dll

riwayat pengobatan, sakit

(depresi dll)
REAKSI EMOSIONAL
- Eksplorasi perhatian dan adanya ketakutan
 Seberapa sering Anda mengalami...

 Apa yang paling Anda khawatirkan saat ini...

(kapan, apa yang dilakukan)
 Seberapa dekat Anda dengan teman-teman atau
keluarga Anda?
 Bagaimana pengaruh...dalam kehidupan Anda?
Isu tentang waktu
 Deadline,

 Waktu kejadian dll

Assessing For Coping Skills
What is the client's environment?

What is the client's problem-solving style?

Is the client impulsive?

Does the client have social support?

Has the client had successes? Failures?

COPING
ADDITIONAL INFORMATION

 Developmental tasks.
 Family History.
 Cultural background.
 Educational history.
 Employment history.
 Social Support/Interpersonal Issues.
 Religion/Spirituality.
 Prior attempts at solving the problem.
Typical coping strategies.
Assessing Emergency Conditions

 Two things to look for are dangerousness and suicidal

tendencies.

 Signs of active crisis are:

Disorganized thinking Immobilization

Impulsivity Helplessness
Hostility Loss of control
Emotional distance Panic
Acute anxiety Indecision
Substance abuse
Assessing For Dangerousness

 Potentially dangerous people may have been victimized

themselves in the past.

 Many have poor impulse control.

 Some may harbor persecutory thoughts.

 Some may hold grudges or seek revenge.

 Many have made lists of those who have harmed them.

 Many have criminal records.

 Many own weapons or know martial arts.

Assessing For Suicide

 Is the client depressed? Is the depression lifting?

 Is the client psychotic?
 Does the client have a history of substance abuse? Poor impulse
control? Violence? Past suicide attempts?
 Has the person recently suffered a loss?
 Does the client have social support?
 Does the client have a plan, the means and the intent?