Sekolah Tinggi Ilmu Kesehatan Stella Maris

Program Profesi Ners

Jl.Maipa 19 Makassar

PENGKAJIAN

Nama Mahasiswa yang Mengkaji : NIM :

Ruang Perawatan : ........................ Tanggal Pengkajian : ..............................

Kamar : ....................... Auto Anamnese : □ ..........................
Tanggal Masuk RS : ....................... Allo Anamnese : □ ..........................

I. IDENTITAS KLIEN
N a m a Inisial : .........................................................................
Umur : .........................................................................
No RM : ………………………………………………….

II. ALASAN MASUK DAN FAKTOR PRESIPITASI

..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Data Saat ini :
...........(1 minggu setelah
pengkajian).......................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
........

III. FAKTOR PREDISPOSISI

A. Pernah mengalami gangguan jiwa di masa lalu
□ Ya □ Tidak
B. Pengobatan sebelumnya
□ Berhasil □ Kurang berhasil □ Tidak berhasil

Form pengkajian kep jiwa/nersPage 1

 C. Pernah melakukan/mengalami/menyaksikan:
Korban/usia Pelaku/usia Saksi/usia
1. Aniaya fisik □ ............... □ .............. □ .............
2. Aniaya seksual □ ............... □ .............. □ .............
3. Penolakan □ ............... □ .............. □ ..............
4. Kekerasan □ ............... □ .............. □ ..............
5. Tindakan kriminal □ ............... □ .............. □ ..............

Jelaskan Point A, B dan C :

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

Masalah Keperawatan :..................................................................................................

D. Adakah anggota keluarga yang pernah menderita gangguan jiwa

□ Ya □ Tidak
Jelaskan (hubungan keluarga, gejala dan riwayat pengobatan) :
....................................................................................................................................
..................................(penyataan
keluarga).....................................................................................................................
.................................................................................................................
....................................................................................................................................
E. Pengalaman masa lalu yang tidak menyenangkan
□ Kegagalan □ Kematian
□ Kehilangan/perpisahan □ Trauma proses tumbuh kembang
Jelaskan :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

IV. PEMERIKSAAN FISIK

A. Tanda-tanda vital :
Tekanan darah : ......................... mmHg
Suhu : ........................ ◦ C

Formpengkajian kep jiwa/nersPage 2

 Nadi : ........................ x/menit
Pernapasan : ........................ x/menit
B. Badan :
Tinggi : ........................ Cm
Berat : ........................ Kg
IMT : .................... Kesimpulan : .......................................................
C. Keluhan fisik :
........................(ada nyeri di bagian mana yang membuat pasien merasa
terganggu)...................................................................................................................
....................................................................................................................................
.............................................................................................................................
Masalah Keperawatan : .................................................................................................

V. STATUS PSIKOSOSIAL
A. Genogram (gambar dan jelaskan isi genogram)

(3 Generasi)

Jelaskan :

..........................(3 Generasi)

....................................................................................................................................
....................................................................................................................................
..........................................................................................................
B. Konsep diri
1. Gambaran diri : ..............................(tubuh yang dsukai dan tidak
disukai)..................................................................................................................
..............................................................................................................................
............................................................................................................
2. Identitas diri :

Formpengkajian kep jiwa/nersPage 3

 ..........(lebih mengenal diri sebgai transgender x pria / wanita
normal)..................................................................................................................
..............................................................................................................................
..
3. Peran diri :
..............................................................................................................................
..........................(dalam keluarga)......dan di lingkungan
sosial.....................................................................................................................
.......................................................................................................
4. Ideal diri :
..............................................................................................................................
.....................(apa yang diharapkan oleh klien dalam status diri dan
sosial)....................................................................................................................
...................................................................................................................
5. Harga diri :
...................(penilaian orang laim terhadap dirinya dihargai atau tidak)
..............................................................................................................................
..............................................................................................................................
...........................................................................................................
Masalah Keperawatan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
C. Hubungan sosial :
1. Orang yang berarti :
..............................................................................................................................
..............................................................................................................................
2. Peran serta dalam kegiatan kelompok/masyarakat :
..............................................................................................................................
..............................................................................................................................
3. Hambatan dalam berhubungan dengan orang lain :
..............................................................................................................................
..............................................................................................................................
Masalah keperawatan :...................................................................................................
D. Spritual
1. Nilai dan keyakinan :

Formpengkajian kep jiwa/nersPage 4

 ..............................................................................................................................
..............................................................................................................................
2. Kegiatan ibadah :
..............................................................................................................................
..............................................................................................................................
Masalah keperawatan : ..................................................................................................
..........................................................................................................................................
.
VI. STATUS MENTAL
A. Penampilan
□ Tidak rapih □ Pakaian tidak sesuai □ Cara berpakaian tidak
seperti biasanya
Jelaskan :
....................................................................................................................................
....................................................................................................................................
B. Pembicaraan
□ Cepat □ Keras □ Gagap □ Apatis
□ Lambat □ Inkoheren □ Membisu □ Tidak mampu memulai
□ Perseverasi
Jelaskan :
....................................................................................................................................
....................................................................................................................................
C. Aktivitas Motorik
□ Lesu □ Tegang □ Gelisah □ Agitasi (gerakan
motorik yang menujukkan kegelisahan)
□ TIK □ Grimace (gerakan otot waja yang berubah rubah yg tidak
dapat dikontrol oleh pasien) □ Tremor □ Kompulsif (hal hal yang
tidak perlu sering dilakukan brulang)
Jelaskan :
....................................................................................................................................
....................................................................................................................................
D. Alam Perasaan
□ Sedih □ Ketakutan □ Putus asa
□ Khawatir □ Gembira berlebihan/euforia
Jelaskan :
....................................................................................................................................
....................................................................................................................................

Formpengkajian kep jiwa/nersPage 5

 E. Afek (ekspresi)
□ Datar □ Tumpul(hanya bereaksi bila ada stimulus yang kuat)
□ Labil(emosi yang berubahrubah) □ Tidak sesuai
Jelaskan :
....................................................................................................................................
....................................................................................................................................
F. Interaksi Selama Wawancara
□ Bermusuhan □ Tidak kooperatif □ Mudah tersinggung
□ Kontak mata kurang(acuh tak acuh) □ Defensif (selalu mempertahankan apa
yangdipikirkan) □ Curiga
Jelaskan :
....................................................................................................................................

G. Persepsi : Halusinasi
□ Pendengaran □ Penglihatan □ Perabaan
□ Pengecapan □ Penghiduan
Jelaskan :
....................................................................................................................................
...............................................................................................................................
H. Proses Pikir
□ Sirkumtansial (berbelitbelitsampaitujuan) □ Tangensial (berbelibelit
tidak sampai tujuan) □ Kehilangan asosias
(pebicaraantidkadahubungan1kalimatdengankalimatlain)i
□ Flight of ideas (pembicaraanloncatloncatbelumselesai1sudahpindah1)
□ Blocking (berbicara berhentiberhenti sepertiada tahanan)

Jelaskan :
....................................................................................................................................
....................................................................................................................................
I. Isi Pikir
□ Obsesi (ada rangsangan dari luar menyebabkan pikiran yg sulit dihilangkan)
□ Fobia □ Hipokondria
(keyakinanadaanggotatubuhyangterganggu)
□ Depersonalisasi(merasaasinterhadaporanglainataubahkanpadadirinyasendiri)
□ Pikir
Magis(kemampuanmelakukanhalyangmustahildiluarnalarmanusia)
□ Ide terkait(suatukejadianyangaddilingkunganyangterkaitdirinya)

Formpengkajian kep jiwa/nersPage 6

 Waham :
□ Agama □ Somatik □ Kebesaran
□ Curiga □ Nihilistik □ Sisip
pikir(idepikiranoranglainyangdisisipkandipkirannya)
□ Siar pikir(klienmengetahuiapayangdiapikirkanitudipahamiolehoranglain)
□ Kontrol pikir (pikiran yang dikontroldariluar)
Jelaskan :
....................................................................................................................................
....................................................................................................................................
J. Tingkat Kesadaran
□ Bingung □ Sedasi □
Stupor(gerakanyangberulangulangdalamsikapcanggungtapikliemmengetahuiapaya
ngterjadidilingkungan)
Disorientasi :
□ Waktu □ Tempat □ Orang
Jelaskan :
....................................................................................................................................
....................................................................................................................................
K. Memori
□ Gangguan daya ingat jangka panjang
□ Perubahan proses pikir pendek (tidakdapatmengingatminggumingguterakhirini)
□ Gangguan daya ingat saat ini
□ Konfabulasi
Jelaskan :
....................................................................................................................................
....................................................................................................................................
L. Tingkat Konsentrasi dan Berhitung
□ Mudah beralih
□ Tidak mampu berkonsentrasi
□ Tidak mampu berhitung sederhana
Jelaskan :
....................................................................................................................................
....................................................................................................................................
M. Kemampuan Penilaian
□ Gangguan ringan(kliendapatmengambilkeputusan) □
Gangguan bermakna(klientidakdapatmengembil keputusan)
Jelaskan :

Formpengkajian kep jiwa/nersPage 7

 ....................................................................................................................................
....................................................................................................................................
N. Daya Tilik Diri (Insight)
□ Mengingkari penyakit yang diderita
□ Menyalahkan hal-hal di luar dirinya
Jelaskan :
....................................................................................................................................
....................................................................................................................................
Masalah keperawatan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
VII. MEKANISME KOPING
Adaptif Maladaptif
□ Bicara dengan orang lain □ Minum alkohol
□ Mampu menyelesaikan masalah □ Reaksi lambat/berlebihan
□ Tenik relaksasi □ Bekerja berlebihan
□ Aktivitas konstruktif □ Menghindar
□ Olahraga □ Menciderai diri
□ Lain-lain
Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Masalah keperawatan : ..................................................................................................

VIII. KEBUTUHAN PERSIAPAN PULANG

Bantuan minimal Bantuan total
A. Makan □ □
B. BAB dan BAK □ □

C. Mandi □ □
D. Berpakaian dan berhias □ □
E. Penggunaan Obat □ □
F. Istirahat dan Tidur
□ Tidur siang :
....................................................................................................................................

Formpengkajian kep jiwa/nersPage 8

 □ Tidur malam :
....................................................................................................................................
□ Kegiatan sebelum/setelah tidur :
....................................................................................................................................
....................................................................................................................................
G. Pemeliharaan Kesehatan
1. Perlu perawatan lanjutan □ Ya □ Tidak
2. Sistem pendukung □ Ya □ Tidak
H. Kegiatan di dalam rumah
1. Mempersiapkan makanan □ Ya □ Tidak
2. Menjaga kebersihan rumah □ Ya □ Tidak
3. Mencuci pakaian □ Ya □ Tidak
4. Pengaturan keuangan □ Ya □ Tidak
I. Kegiatan di luar rumah
1. Belanja keperluan sehari-hari □ Ya □ Tidak
2. Transportasi □ Ya □ Tidak
Jelaskan :
....................................................................................................................................
....................................................................................................................................
Masalah keperawatan : ..................................................................................................

IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

□ Masalahdengandukungankelompok

……………………………………………………………………………………………….

□ Masalahdenganpendidikan

……………………………………………………………………………………………….

□ Masalahdenganpekerjaan

…………………………………………………………………………………………………

□ Masalahdenganperumahan

…………………………………………………………………………………………………

□ Masalahdenganekonomi

Formpengkajian kep jiwa/nersPage 9

 …………………………………………………………………………………………………

□ Masalahdenganpelayanankesehatan

……………………………………………………………………………………………….

Masalah keperawatan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

X. DATA MEDIK
1. Diagnosa Medik :
....................................................................................................................................
2. Therapi Medik :

Nama Obat/ Dosis untuk Farmakokinetik dan

Golongan Pasien farmakodinamik obat

Mahasiswa yang mengkaji

(_______________________)

Formpengkajian kep jiwa/nersPage 10