FORMAT PENGKAJIAN

ASUHAN KEPERAWATAN JIWA

STIKES HANG TUAH SURABAYA

Nama mahasiswa
NIM
Ruangan
Pengkajian diambil
Diagnosa medis

I.

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IDENTITAS KLIEN
No. RM :
Nama

Inisial
Umur

: L/P
: .......... 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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4. Adakah anggota keluarga yang mengalami gangguan jiwa?

a. Ya
b. Tidak
Bila ada isi dibawah ini :
Hubungan keluarga
Gejala
a. ..............................
a. ..............................
b. ..............................
b. ..............................

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. 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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5. Istirahat dan tidur

Tidur siang lama : ................ s/d .....................
Tidur malam lama : ................ s/d .....................
Kegiatan sebelum/sesudah tidur :
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6. Penggunaan obat
a. Bantuan minimal
b. Bantuan total
7. Pemeliharaan kesehatan
Perawatan lanjutan
a. Ya
b. Tidak
Perawatan pendukung
a. Ya
b. Tidak
8. Kegiatan di dalam rumah
Mempersiapkan makanan
a. Ya
b. Tidak
Menjaga kerapihan rumah
a. Ya
b. Tidak
Mencuci pakaian
a. Ya
b. Tidak
Pengaturan keuangan
a. Ya
b. Tidak
9. Kegiatan di luar rumah
Belanja
a. Ya
b. Tidak
Transportasi
a. Ya
b. Tidak
Lain-lain
a. Ya
b. Tidak
Jelaskan :
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Masalah keperawatan :
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VIII. MEKANISME KOPING
Adaptif
1. Bicara dengan orang lain
2. Mampu menyelesaikan masalah
3. Teknik relaksasi
4. Aktivitas konstruktif
5. Olah raga
Lainnya
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Maladaptif
1. Minum alkohol
2. Reaksi lambat / berlebih
3. Bekerja berlebihan
4. Menghindar
5. Mencederai diri
Lainnya
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Masalah keperawatan :
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IX.

MASALAH PSIKOSOSIAL DAN LINGKUNGAN

1. Masalah
dengan
dukungan
kelompok,
spesifik
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2. Masalah
berhubungan
dengan
lingkungan,
spesifik
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3. Masalah
dengan
pendidikan,
spesifik
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4. Masalah
dengan
pekerjaan,
spesifik
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5. Masalah
dengan
perumahan,
spesifik
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6. Masalah
ekonomi,
spesifik
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7. Masalah
dengan
pelayanan
kesehatan,
spesifik
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8. Masalah
lainnya,
spesifik
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Masalah keperawatan :
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X. PENGETAHUAN KURANG TENTANG
1. Penyakit jiwa
3. Faktor presipitasi
5. Koping
2. Sistem pendukung
4. Penyakit fisik
6. Obat-obatan
Lainnya
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Masalah keperawatan :
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XI. ASPEK MEDIK
1. Diagnosa medik :
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2. Terapi medik

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XII. DAFTAR DIAGNOSA KEPERAWATAN

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Surabaya, .....................

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POHON MASALAH
Akibat

Core problem

Penyebab

ANALISA DATA
Nama klien
Umur
No.

: ..............................................
: ..............................................
Data (Symptom)

Ruangan/kamar : ..............................................
No. RM
: ..............................................

Penyebab (Etiologi)

Masalah (Problem)

INTERVENSI KEPERAWATAN
No

Tanggal

Diagnosa
Keperawatan

Tujuan

Kriteria evaluasi

Intervensi

IMPLEMENTASI DAN EVALUASI

No

Tanggal/jam

Implementasi

Evaluasi

Paraf

STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Nama Klien
Umur
Masalah

:
:
:

Pertemuan ke- : ...............................................

Dx. Medis
: ...............................................

A. Proses Keperawatan
1. Kondisi pasien
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2. Masalah/diagnosis keperawatan
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3. Tujuan keperawatan
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B. Strategi Komunikasi
1. Orientasi
a. Salam terapeutik
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b. Evaluasi validasi
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c. Kontrak
1) Topik
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2) Waktu
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3) Tempat
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2. Kerja
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3. Terminasi
a. Evaluasi subjektif (wawancara/sanjungan)
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b. Evaluasi objektik (wawancara dan observasi)
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c. Tindak lanjut
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d. Kontrak yang akan datang
1) Topik
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2) Waktu
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3) Tempat
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Mahasiswa,

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ANALISA PROSES INTERAKSI

Inisial klien
Status interaksi P K
Lingkungan
Deskripsi Klien
Tujuan interaksi

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:
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:
:

Nama Mahasiswa
Tanggal
Waktu
Tempat

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Deskripsi Klien :

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Lingkungan :

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Komunikasi Verbal

Komunikasi Non - Verbal

Analisa Berpusat
Pada Perawat

Analisa Berpusat
Pada Klien

Rasional

Komunikasi Verbal

Komunikasi Non - Verbal

Analisa Berpusat
Pada Perawat

Analisa Berpusat
Pada Klien

Rasional

Kesan Perawat :

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Mahasiswa,

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