FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

Ruangan Rawat _____________________

A. IDENTITAS KLIEN
1. Inisial
2. Umur
3. Pendidikan
4. Pekerjaan
5. Informan
6. Status perkawinan
7. No.RMK
8. Tanggal Pengkajian
9. Diagnosa Medis

Tanggal Dirawat _____________________

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B. ALASAN MASUK
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C. KELUHAN/KEADAAN KLIEN SAAT INI
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D. FAKTOR PRESIPITASI
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E. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu ?
Ya
Tidak
2. Pengobatan sebelumnya
Berhasil
Kurang berhasil
Tidak berhasil
3. Trauma
Pelaku/Usia Korban/Usia Saksi/Usia
Aniaya fisik

Aniaya seksual
Penolakan
Kekerasan dalam keluarga
Tindakan kriminal
Jelaskan No. 1, 2, 3 :
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Masalah keperawatan:
Gangguan pertumbuhan dan perkembangan
Gangguan proses keluarga
Respon pasca trauma
Resiko perilaku kekerasan
Berduka disfungsional
4. Adakah anggota keluarga yang mengalami gangguan jiwa
Ya
Tidak
Hubungan keluarga
Gejala
Riwayat pengobatan/perawaran
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____Masalah Keperawatan :
Koping keluarga tidak efektif : ketidakmampuan
Koping keluarga tidak efektif : Penurunan

 Koping keluarga : potensial pertumbuhan

5. Pengalaman masa lalu yang tidak menyenangkan
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Masalah Keperawatan :
Gangguan pertumbuhan dan perkembangan
Gangguan proses keluarga
Respon pasca trauma
F. PEMERIKSAAN FISIK
1. Tanda vital
: TD : __________ N : ________
R : _________ T : _______________
2. Ukur
: TB : __________ BB : ________
3. Keluhan fisik :
Ya
Tidak
Jelaskan
:
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Masalah Keperawatan :
Resiko gangguan suhu tubuh
Kerusakan integritas kulit
Defisit volume cairan
Kerusakan
integritas
Kelebihan volume cairan
jaringan
Resiko infeksi
gangguan eliminasi fases
Gangguan nutrisi < dari kebutuhan
gangguan eliminasi urin
perubahan
membrane
tubuh
Gangguan nutrisi > dari kebutuhan
mukosa oral
tubuh
Gangguan menelan

G. PSIKOSOSIAL
1. Genogram

Keterangan

Jelaskan
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Masalah Keperawatan :
Koping keluarga tidak efektif : ketidakmampuan
Koping keluarga tidak efektif : penurunan
Koping keluarga : potensial pertumbuhan
2.

Konsep diri
a Gambaran diri

b Identitas

c Peran

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d Ideal diri

e Harga diri

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Masalah Keperawatan :
Gangguan citra tubuh
Gangguan identitas pribadi
Gangguan konsep diri
Harga diri rendah
3.
a

Hubungan Sosial
Orang yang berarti

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b Peran serta dalam kegiatan kelompok / masyarakat :
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c Hambatan dalam berbuhungan dengan orang Lain :
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Masalah Keperawatan :
Hambatan komunikasi verbal
Isolasi sosial
Hambatan interaksi social
Perubahan performa peran
4.

Spiritual
a Nilai dan keyakinan : ______________________________________________________
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b Kegiatan ibadah
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Masalah Keperawatan :
Distress spiritual

H. STATUS MENTAL
1. Penampilan
Tidak rapi

Penggunaan pakaian
tidak sesuai

Cara berpakaian tidak seperti

biasanya

Penjelasan
:
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Masalah Keperawatan :
Defisit perawatan diri
2. Pembicaraan
Cepat

Keras

Gagap

Inkoheren

Apatis

Lambat

Membisu

Tidak mampu memulai

Pembicaraan

Loghorea
Echolalia
Penjelasan
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Masalah Keperawatan :
Hambatan komunikasi verbal

3. Aktivitas Motorik:
Lesu

Tegang

Gelisah

Agitasi

TIK

Grimasen

Tremor

Kompulsif

Penjelasan
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Masalah Keperawatan :
Resiko cedera

 Intoleransi aktivitas
4. Alam perasaaan
Sedih
Ketakutan
Putus asa
Khawatir
Gembira berlebihan
Penjelasan
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Masalah Keperawatan :
Resiko cedera
Ansietas
Ketakutan
Ketidakberdayaan
Ketidakmampuan
Resiko membahayakan diri sendiri
5. Afek
Datar
Tumpul
Labil
Tidak sesuai
Penjelasan
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Masalah Keperawatan :
Resiko cedera
Hambatan komunikasi
perubahan performa peran
6. lnteraksi selama wawancara
bermusuhan

Tidak kooperatif

Mudah tersinggung

Kontak mata (-)

Defensif

Curiga

Penjelasan
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Masalah Keperawatan :
Hambatan komunikasi verbal
Isolasi sosial
Hambatan interaksi sosial
Resiko perilaku kekerasan
Resiko membahayakan diri sendiri
Perubahan performa peran

7. Persepsi
Pendengaran

Penglihatan

Pengecapan

Penghidu

Perabaan

Penjelasan
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Masalah Keperawatan :
Gangguan sensoris / persepsi
8. Proses Pikir
sirkumtansial

tangensial

kehilangan asosiasi

flight of idea

blocking

pengulangan pembicaraan/persevarasi

Neologisme
Penjelasan
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Masalah Keperawatan :
Gangguan proses piker
9. Isi Pikir
Obsesi

Fobia

Hipokondria

depersonalisasi

ide yang terkait

pikiran magis

Somatik

Kebesaran

Waham
Agama

Curiga

nihilistic
sisip pikir
Siar pikir
Kontrol pikir
Penjelasan
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Masalah Keperawatan :
Gangguan proses pikir
10. Tingkat kesadaran
bingung

sedasi

stupor

Disorientasi
waktu
tempat
orang
Penjelasan
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Masalah Keperawatan :
Gangguan proses pikir
Resiko cedera
11. Memori
Gangguan daya ingat jangka panjang

gangguan daya ingat jangka pendek

gangguan daya ingat saat ini

konfabulasi

Penjelasan
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Masalah Keperawatan :
Gangguan proses pikir
12. Tingkat konsentrasi dan berhitung
mudah beralih
tidak mampu konsentrasi
Tidak mampu berhitung sederhana
Penjelasan
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Masalah Keperawatan :
Gangguan proses pikir
Isolasi sosial
13. Kemampuan penilaian
Gangguan ringan
gangguan bermakna
Penjelasan
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Masalah Keperawatan :
Gangguan proses pikir
14. Daya tilik diri
mengingkari penyakit yang diderita
menyalahkan hal-hal diluar dirinya
Penjelasan
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Masalah Keperawatan :
Ketidak efektifan penatalaksanaan program terapeutik
Ketidakpatuhan (resti)
Gangguan proses piker
I. KEBUTUHAN PERSIAPAN PULANG
1. Makan
Bantuan minimal
Bantuan total
Penjelasan
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2. BAB/BAK
Bantuan minimal

Bantual total

Penjelasan
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3. Mandi
Bantuan minimal
Bantuan total
Penjelasan
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4. Berpakaian/berhias
Bantuan minimal
Bantual total
Penjelasan
:
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5. Istirahat dan tidur
Tidur siang lama

: .s/d

Tidur malam lama

: s/d

Kegiatan sebelum / sesudah tidur

Penjelasan
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6. Penggunaan obat
Bantuan minimal
Bantual total
Penjelasan
:
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7. Pemeliharaan Kesehatan
Perawatan lanjutan

Ya

tidak

Perawatan pendukung
Ya
tidak
Penjelasan
:
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8. Kegiatan di dalam rumah

Mempersiapkan makanan

Ya

tidak

Menjaga kerapihan rumah

Ya

tidak

Mencuci pakaian

Ya

tidak

Pengaturan keuangan
Ya
tidak
Penjelasan
:
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9. Kegiatan di luar rumah
Belanja

Ya

tidak

Transportasi

Ya

tidak

Lain-lain
Ya
tidak
Penjelasan
:
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Masalah Keperawatan :
Gangguan pemeliharaan kesehatan
Gangguan eliminasi
Defisit perawatan diri
Gangguan nutrisi
Gangguan pola tidur
Ketidak efektifan penatalaksanan program terafetik
Ketidakpatuhan
Konflik pengambilan keputusan

J.

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 _______________
Lainnya : __________________
Penjelasan
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Masalah Keperawatan :
gangguan penyesuaian diri
koping individu tidak efektif
K. 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 :
Gangguan pemeliharaan kesehatan
Gangguan konsep diri
Ketidak berdayaan
Ketidak mampuan
Konflik peran menjadi orang tua
Sindrom stres akibat pindah
L. KURANG PENGETAHUAN TENTANG:
Penyakit jiwa

system pendukung

Faktor presipitasi

penyakit fisik

Koping

obat-obatan

Lainnya :
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Masalah Keperawatan :
Ketidakefektifan penatalaksanan program terapetik
Ketidakpatuhan
Defisit pengetahuan (uraikan)
M. ASPEK PENUNJANG
Diagnosa Medik :
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Hasil Laboratorium :
Pemeriksaan
HEMATOLOGI
Hemoglobin
Eritrosit
Leukosit
Hematokrit
Trombosit
HITUNG JENIS
Gran%
Limfosit%
MID%
KIMIA HATI
SGOT
SGPT
WIDAL
S.Typhi O
S.Typhi H
S.Parayphi A
S.Parayphi B
KIMIA GULA DARAH
Gula Darah Sewaktu
KIMIA GINJAL
Ureum
Creatinin
LAIN-LAIN
HBsAg

Hasil

Nilai Rujukan

Satuan

13,0 16,0
4,5 5,5
5,0 10,0
45 55
150 400

g/dl
juta/l
ribu/l
vol%
ribu/l

50.0-70.0
25.0-40.0
4.0-11.0

ribu/l
ribu/l
ribu/l

0-46
0-45

U/l
U/l

< 200

mg/dl

10-50
0.7-1.4

mg/dl
mg/dl

Negatif

Terapi Medik :
Nama Obat

Dosis

Indikasi
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N. ANALISA DATA
Data Maladaftif
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Masalah Keperawatan

Etiologi

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Masalah Keperawatan

Etiologi

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O. DAFTAR MASALAH KEPERAWATAN
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P. DIAGNOSA KEPERAWATAN
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Q. POHON MASALAH

R. TAHAP PENANGANAN KLIEN

1. Skor Kategori Klien
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2. Tahap Penanganan Fase
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3. Tujuan Pengobatan
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4. Pengkajian Keperawatan
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5. Intervensi Keperawatan
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6. Hasil yang Diharapkan
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Banjar,
2014
Pelaksana Pengkajian

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