FORMAT ASUHAN KEPERAWATAN JIWA

PENGKAJIAN

TanggalPengkajian:..................... NomorRegister :............................

RuanganRawat :...................... DiagnosaMedis :............................

TanggalDirawat:.......................

IDENTITASPASIEN

Nama :.......................................

Umur :.......................................

StatusPerkawinan :.......................................

Agama :.......................................

SukuBangsa :.......................................

Pendidikan :.......................................

Alamat :.......................................

SumberInformasi :.......................................

ALASANMASUK

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FAKTORPREDISPOSISI
Pernahmengalamigangguan jiwa dimasalalu?()Ya()Tidak
Pengobatansebelumnya()Berhasil ( )KurangBerhasil ( )
TidakBerhasil
Pelaku/UsiaKorban/UsiaSaksi/Usia
 AniayaSeksual ( )()()( )()( )
Penolakan ( )()()( )()( )
KekerasandalamKeluarga ()( )()( )( )()
Jelaskana,b,danc:...............................................................................................

..................................................................................................................................

MasalahKeprawatan: .............................................................................................

Adakah anggota keluarga yang mengalami gangguan jiwa()

Ya()TidakHubungankeluarga Gejala
RiwayaTpengobatan/perawatan
 Pengalamanmasalaluyangtidakmenyenangkan
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MasalahKeperawatan:................................................................................
PEMERIKSAANFISIK
Tanda vital
:TD
:............................
N :.............................
S :.........................

P :......................

Ukur:

TB:........................

BB:.....................

KeluhanFisik :( )Ya ( )Tidak

Jelaskan:.................................................................................................................

..................................................................................................................................

MasalahKeperawatan:..................................................................................
 PSIKOSOSIAL
Genogram : Gambarkan

Jelaskan:
..........................................................................................................................................
..........................................................................................................................................
............

Masalah Keperawatan
:.....................................................................................................

KonsepDiri
1)Gambaran diri:........................................................................................
2)Identitas :.........................................................................................
3)Peran :...........................................................................................
4)IdealDiri :.........................................................................................
5)Harga Diri :......................................................................................

MasalahKeperawatan:...................................................................................

HubunganSosial
1)Orangyangberarti:.......................................................................................
2)Peransertadalamkegiatankelompko/masyarakat:..................................
3)Hamabatan dalamberhubungan denganoanglain:.......................................

MasalahKeperawatan:.......................................................................................

Spiritual
1)Nilaidankeyakinan :.........................................................................
2)Kegiatanibadah :..........................................................................
STATUSMENTAL
Penampilan

() Tidak rapi ()Penggunaan pakaian tidak

sesuai()caraberpakaian tidaksepertibiasanya

Jelaskan :.......................................................................................

MasalahKeperawatan:............................................................................

Pembicaraan

( )Cepat ()Keras ()Gagap ()Inkoheren

()Apatis()Lambat ()Membisu ()Tidak

mampiu memulai pembicaraanJelaskan

:.........................................................................................

MasalahKeperawatan:.................................................................................

AktivitasMotorik
 Jelaskan :........................................................................................

MasalahKeperawatan :................................................................................

AlamPerasaan

( )Sedih ()Ketakutan ()Putusasa

()Khawatir ()Gembiraberlebihan

Jelaskan :...........................................................................................

MasalahKeperawatan :..................................................................................

Afek

( )Datar ()Tumpul ()Labil ()Tidak sesuai

Jelaskan :...........................................................................................

MasalahKeperawatan:..................................................................................
Interaksiselamawawancara

()Bermusuhan ( )Tidak kooperatif ()Mudahtersinggung()

Kontakmatakurang() Defensif ()Curiga

MasalahKeperawatan :........................................................................................
()Pendengaran ()Penglihatan ( )Perabaan
 Jelaskan :............................................................................................................

MasalahKeperawatan: .....................................................................................

h.ProsesPikir
() Sirkumtansi ()Tangensial ()Kehilangan
Asosiasi()Flightofideas ( ) Blocking
Jelaskan :..............................................................................................................

MasalahKeperawatan:.......................................................................................
()Obsesi ()Fobia ()Hipokondria
()Depersonalisasi ()Ideyangterkait () Pikiran magis
 Jelaskan :.................................................................................................

MasalahKeperawatan :.........................................................................

TingkatKesadaran
( )Bingung ()Sedasi
()StuporDisorientasi:
Jelaskan :.......................................................................................................

MasalahKeperawatan :..............................................................................

Memori

()Gangguan daya ingat jangka

panjang()Gangguandaya ingat

jangkapendek
 Jelaskan :.............................................................................................

MasalahKeperawatan :...................................................................................

( )Mudahberalih ()Tidak mampu

berkonsentrasi()Tidak mampu berhitungsederhana
Jelaskan :...........................................................................................
MasalahKeperawatan:.................................................................................
KemampuanPenilaian
()Gangguanringan ()Gangguan bermakna
Jelaskan :..........................................................................................
MasalahKeperawatan :................................................................................

Dayatilikdiri
()Mengingkari penyakit yangdiderita
()Menyalahkanhal–haldiluardirinya
Jelaskan :........................................................................................
MasalahKeperawatan :.............................................................................

KEBUTUHANPERSIAPANPULANG
Makan
()Bantuan minimal ()Bantuan total

.........................................................................................................................

BAB/BAK
()Bantuan minimal ()Bantuan total
 ....................................................................................................................................
...
Mandi
()Bantuan minimal ()Bantuan total
....................................................................................................................................
.....
Berpakain/berhias
()Bantuan minimal ()Bantuan total
....................................................................................................................................
......
Istirahatdantidur
( )Tidur sianglama :
......................................s/d..................................................
() Tidur malamlama :
......................................s/d..................................................
( ) Kegiatan sebelum/sesudah tidur :
...............................s/d.......................................
Penggunaanobat
()Bantuan minimal ()Bantuan total
....................................................................................................................................
....
Pemeliharankesehatan Ya

TidakPerawatanlanjutan ( ) ()
Kegiatandidalamrumah Ya

TidakMempersiapkanmakanan ( ) ()
Mencucipakaian ( ) ( )
Pengaturankeuangan ( ) ( )
Kegiatandi luarrumah Ya Tidak
Belanja ( ) ( )
Transportasi ( ) ( )
Lain–lain ( ) ( )

Jelaskan :................................................................................
 MasalahKeperawatan:.....................................................................

MEKANISMEKOPING
Adaftif Maladaftif

( )Bicaradengan oranglain ()MinumAlkohol

()Mampu menyelesaikanmasalah ()Reaksi lambat /
berlebih() Teknikrelaksasi ()
Bekerjaberlebihan
 ()Olahraga ()Mencederaidiri
( )Lainnya............................. () Lainnya..............................

Jelasakan :.....................................................................................
MasalahKeperawatan:................................................................................

MASALAHPSIKOSOSIALDANLINGKUNGAN
()Masalahdengan dukungankelompok,spesifik........................................
()Masalahberhubungandenganlingkungan,spesifik................................
()Masalahdengan pendidikan,spesifik .....................................................
()Masalahdenganpekerjaan,spesifik........................................................
()Masalah denganperumahan, spesifik .....................................................
()Masalahekonomi,spesifik.......................................................................
()Masalahdenganpelayanankesehatan,spesifik..........................................
()Masalahlainnya,spesifik.........................................................................
()Masalahdengandukunganlingkungan.........................................................
MasalahKeperawatan:........................................................................................

PENGETAHUANKURANGTENTANG
()Penyakitjiwa ( )Sistempendukung () Faktorpresipitasi
()Penyakitfisik ()Koping () Obat-obatan ()Lainnya

MasalahKeperawatan:.............................................................................................