Format Pengkajian Keperawatan Jiwa
Format Pengkajian Keperawatan Jiwa
I. IDENTITAS KLIEN
No. RM : .............................................................................................................................................
Nama : .............................................................................................................................................
Inisial : L / P
Umur : .......... tahun
II. ALASAN MASUK
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III. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu?
a. Ya
b. Tidak
2. Pengobatan sebelumnya?
a. Berhasil
b. Kurang berhasil
c. Tidak berhasil
3. Faktor :
Aniaya fisik
a. Pelaku : ..................................................................................... Usia : ............. tahun
b. Korban : ..................................................................................... Usia : ............. tahun
c. Saksi
: ..................................................................................... Usia : ............. tahun
Aniaya seksual
a. Pelaku : ..................................................................................... Usia : ............. tahun
b. Korban : ..................................................................................... Usia : ............. tahun
c. Saksi
: ..................................................................................... Usia : ............. tahun
Penolakan
a. Pelaku : ..................................................................................... Usia : ............. tahun
b. Korban : ..................................................................................... Usia : ............. tahun
c. Saksi
: ..................................................................................... Usia : ............. tahun
Kekerasan dalam rumah tangga
a. Pelaku : ..................................................................................... Usia : ............. tahun
b. Korban : ..................................................................................... Usia : ............. tahun
c. Saksi
: ..................................................................................... Usia : ............. tahun
Tindakan kriminal
a. Pelaku : ..................................................................................... Usia : ............. tahun
b. Korban : ..................................................................................... Usia : ............. tahun
c. Saksi
: ..................................................................................... Usia : ............. tahun
Jelaskan no. 1, 2, 3
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Masalah keperawatan
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Riwayat
pengobatan/perawatan
a. ..............................
b. ..............................
Masalah keperawatan :
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5. Pengalaman masa lalu yang tidak menyenangkan
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Masalah keperawatan :
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IV. PENGKAJIAN FISIK
1. Tanda Vital
TD : mm/hg N : x/menit S : C P : x/menit
2. Ukur tubuh
TB : cm BB : kg
3. Keluhan Fisik
a. Ya
b. Tidak
Jelaskan :
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Masalah Keperawatan :
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V. PSIKOSOSIAL
1. Genogram :
Jelaskan :
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Masalah keperawatan :
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2
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 :
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c. Hambatan dalam berhubungan dengan orang lain :
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Masalah keperawatan :
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4. Spiritual
a. Nilai dan keyakinan :
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b. Kegiatan ibadah :
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Masalah keperawatan :
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VI. STATUS MENTAL
1. Penampilan
a. Tidak rapi
c. Cara berpakaian tidak seperti biasanya
b. Penggunaan pakaian tidak sesuai
Jelaskan :
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Masalah keperawatan :
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2. Pembicaraan
a. Cepat
e. Apatis
h. Tidak mampu
b. Keras
f. Lambat
memulai
c. Gagap
g. Membisu
pembicaraan
d. Inkoheren
Jelaskan :
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Masalah keperawatan :
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3. Aktivitas motorik
a. Lesu
c. Gelisah
e. TIK
g. Tremor
b. Tegang
d. Agitasi
f. Grimasen
h. Kompulsif
Jelaskan :
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Masalah keperawatan :
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4. Alam perasaan
a. Sedih
c. Gembira
e. Khawatir
b. Putus asa
d. Ketakutan
f. Berlebihan
Jelaskan :
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Masalah keperawatan :
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5. Afek
a. Datar
b. Tumpul
c. Labil
d. Tidak sesuai
Jelaskan :
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Masalah keperawatan :
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6. Interaksi selama wawancara
a. Bermusuhan
c. Mudah tersinggung
e. Defensif
b. Tidak kooperatif
d. Kontak mata (-)
f. Curiga
Jelaskan :
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Masalah keperawatan :
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7. Persepsi
a. Pendengaran
c. Perabaan
e. Penghidungan
b. Penglihatan
d. Pengecapan
Jelaskan :
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Masalah keperawatan :
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8. Proses pikir
a. Sirkumtansial
d. Flight of idea
f. Pengulangan
b. Tangensial
e. Blocking
pembicaraan
c. Kehilangan asosiasi
/persevarasi
Jelaskan :
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Masalah keperawatan :
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9. Isi pikiran
a. Obsesi
c. Hipokondria
e. Ide yang terkait
b. Fobia
d. Depersonalisasi
f. Pikiran magis
Waham
a. Agama
d. Curiga
g. Siar pikir
b. Somatik
e. Nihilistic
h. Kontrol pikir
c. Kebesaran
f. Sisip pikir
Jelaskan :
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Masalah keperawatan :
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10. Tingkat kesadaran
a. Bingung
b. Sedasi
c. Stupor
Disorientasi
a. Waktu
b. Tempat
c. Orang
Jelaskan :
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Masalah keperawatan :
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11. Memori
a. Gangguan daya ingat jangka panjang
c. Gangguan daya ingat jangka pendek
b. Gangguan daya ingat saat ini
d. Konfabulasi
Jelaskan :
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Masalah keperawatan :
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12. Tingkat konsentrasi dan berhitung
a. Mudah beralih
c. Tidak mampu konsentrasi sederhana
b. Tidak mampu berhitung
Jelaskan :
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Masalah keperawatan :
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13. Kemampuan penilaian
a. Gangguan ringan
b. Gangguan bermakna
Jelaskan :
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Masalah keperawatan :
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14. Daya tilik diri
a. Mengingkari penyakit yang di derita
b. Menyalahkan hal-hal di luar dirinya
Jelaskan :
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Masalah keperawatan :
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VII. KEBUTUHAN PERSIAPAN PULANG
1. Makan
a. Bantuan minimal
b. Bantuan total
2. BAB / BAK
a. Bantuan minimal
b. Bantuan total
Jelaskan :
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Masalah keperawatan :
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3. Mandi
a. Bantuan minimal
b. Bantuan total
4. Berpakaian / berhias
a. Bantuan minimal
b. Bantuan total
Jelaskan :
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Masalah keperawatan :
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Mahasiswa
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