FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

Ruangan Rawat _____________________ Tanggal Dirawat _____________________

A. IDENTITAS KLIEN
1. Inisial :_____________________(L/P)
2. Umur :_____________________
3. Pendidikan : _____________________
4. Pekerjaan : ____________________
5. Informan : _____________________
6. Status perkawinan : __________________
7. No.RMK : _____________________
8. Tanggal Pengkajian : _____________________

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
tubuh perubahan membrane
Gangguan nutrisi > dari kebutuhan mukosa oral
tubuh
Gangguan menelan

G. PSIKOSOSIAL
1. Genogram
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Keterangan :
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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 : ____________________________________________________
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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 :
Gangguan citra tubuh
Gangguan identitas pribadi
Gangguan konsep diri
Harga diri rendah

3. Hubungan Sosial
a 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 Cara berpakaian tidak seperti
tidak sesuai 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 Perabaan

 Pengecapan Penghidu

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

Waham

Agama Somatik Kebesaran 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 Hasil Nilai Rujukan Satuan
HEMATOLOGI
 Hemoglobin 13,0 16,0 g/dl
Eritrosit 4,5 5,5 juta/l
Leukosit 5,0 10,0 ribu/l
Hematokrit 45 55 vol%
Trombosit 150 400 ribu/l
HITUNG JENIS
Gran% 50.0-70.0 ribu/l
Limfosit% 25.0-40.0 ribu/l
MID% 4.0-11.0 ribu/l
KIMIA HATI
SGOT 0-46 U/l
SGPT 0-45 U/l
WIDAL
S.Typhi O
S.Typhi H
S.Parayphi A
S.Parayphi B
KIMIA GULA DARAH
Gula Darah Sewaktu < 200 mg/dl
KIMIA GINJAL
Ureum 10-50 mg/dl
Creatinin 0.7-1.4 mg/dl
LAIN-LAIN
HBsAg Negatif

Terapi Medik :
Nama Obat Dosis Indikasi
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II. ANALISA DATA
Data Maladaftif Masalah Keperawatan
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Data Maladaftif Masalah Keperawatan
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N. DAFTAR MASALAH KEPERAWATAN

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O. DIAGNOSA KEPERAWATAN
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P. POHON MASALAH
Q. TAHAP PENANGANAN KLIEN
1. Skor Kategori Klien : ..............................................................................................
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, 2016
Pelaksana Pengkajian
M.Akbar Nugraha, S.Kep