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 PASIEN 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/perawatan
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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

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 : ____________________________________________________
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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 pikir
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 pikir
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/µl
Leukosit 5,0 – 10,0 ribu/µl
Hematokrit 45 – 55 vol%
Trombosit 150 – 400 ribu/µl
HITUNG JENIS
Gran% 50.0-70.0 ribu/µl
Limfosit% 25.0-40.0 ribu/µl
MID% 4.0-11.0 ribu/µl
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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Terapi Medik :
Jenis Obat Dosis Indikasi
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Kontra Indikasi
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N. DAFTAR MASALAH KEPERAWATAN
Data Masalah Keperawatan
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 Data Masalah Keperawatan
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 Data 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 : ........................................................................................
6. Hasil yang Diharapkan : .........................................................................................

Banjarmasin, Mei 2017

Pelaksana Pengkajian

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