Format Pengkajian
Format Pengkajian
JIWA
I. IDENTITAS KLIEN
Nama : …………………….. (L/P)
Umur : …………….. ………
Alamat : ………………………
Pendidikan : .....................................
Agama : ....................................
Status : ....................................
Pekerjaan : ………………………
JenisKel. : ………………………
No CM : ………………………
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DataSekunder
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c. Keluhan Utama Saat Pengkajian
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III. RIWAYAT PENYAKIT SEKARANG (FAKTOR PRESIPITASI)
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IV. RIWAYAT PENYAKIT DAHULU (FAKTOR PREDISPOSISI)
1. Pernah mengalami gangguan jiwa di masa lalu ?
Ya
Tidak
JikaYa,Jelaskan kapan, tanda gejala/keluhan :
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2. Faktor Penyebab/Pendukung :
a. Riwayat Trauma
Usia Pelaku Korban Saksi
1. Aniayafisik ………… ………… ………… …………
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DiagnosaKeperawatan :
b. Pernah melakukan upaya / percobaan / bunuh diri Jelaskan:
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DiagnosaKeperawatan :
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DiagnosaKeperawatan :
d. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
Ya
Tidak
Jika yaJelaskan
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Diagnosa Keperawatan :
e. Riwayat Penggunaan NAPZA
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Diagnosa Keperawatan :
3. Upaya yang telah dilakukan terkait kondisi di atas dan hasilnya :
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Jelaskan :
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Diagnosa Keperawatan :
4. Riwayat Penyakit Keluarga
Anggotakeluarga yang gangguanjiwa ?
Ada
Tidak
Jika ada :
Hubungankeluarga :
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Gejala :
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Riwayat pengobatan :
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Diagnosa Keperawatan :
Jelaskan:
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Diagnosa Keperawatan :
2. Konsep Diri
a. Citra tubuh :
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b. Identitas :
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c. Peran :
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d. Ideal diri :
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e. Hargadiri :
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Diagnosa Keperawatan :
3. Hubungan Sosial
a. Orang yang berarti/terdekat
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b. Peran serta dalam kegiatan kelompok/masyarakat dan hubungan sosial
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c. Hambatandalamberhubungandengan orang lain
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Diagnosa Keperawatan :
4. Spiritual
a. Agama
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b. Pandangan terhadap gangguan jiwa
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Diagnosa Keperawatan:
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2. Kesadaran (Kuantitas)
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3. Tanda vital:
TD : ……. mm/Hg
N :…….. x/menit
S : …….. CO
P : …….. x/menit
4. Ukur:
BB : ……. Kg
TB : ……. Cm
5. Keluhan fisik:
Jelaskan :
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Diagnosa Keperawatan : VII.
STATUS MENTAL
1. Penampilan (Penanpilan usia, cara perpakaian, kebersihan) Jelaskan:
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Diagnosa Keperawatan:
2. Pembicaraan (Frekuensi, Volume, Jumlah, Karakter) :
Jelaskan:
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Diagnosa Keperawatan:
3. Aktifitasmotorik/Psikomotor Kelambatan :
Hipokinesia,hipoaktifitas
Katalepsi
Sub stupor katatonik
Fleksibilitas serea Jelaskan:
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Peningkatan :
Hiperkinesia,hipera Jelaskan:
ktifitas Grimace
Stereotipi Otomatisma
Negativisme
Gaduh Gelisah
Katatonik Reaksikonversi
Mannarism Tremor
Katapleksi Verbigerasi
Tik Berjalankaku/rigid
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Diagnosa Keperawatan :
4. Mood dan Afek
a. Mood
Depresi Khawatir
Ketakutan Anhedonia
Euforia Kesepian
Lain lain
Jelaskan
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b. Afek
Sesuai Tidak sesuai
Tumpul/dangkal/datar Labil
Jelaskan:
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Diagnosa Keperawatan
Jelaskan:
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Diagnosa Keperawatan
6. Persepsi Sensorik
a. Halusinasi
Pendengaran
Penglihatan
Perabaan
Pengecapan
Penciuman
b. Ilusi
Ada
Tidakada
Jelaskan:
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Diagnosa Keperawatan
7. Proses Pikir
a. ArusPikir:
Koheren Inkoheren
Logorhoe Neologisme
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b. Isi Pikir
Obsesif Fobia,sebutkan…………..
Ekstasi Waham:
Fantasi o Agama
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Alienasi o Somatik/hipokondria
Pikiran bunuh diri o Kebesaran
Preokupasi o Kejar / curiga
Pikiran isolasisosial o Nihilistik
Ide yang terkait o Dosa
PikiranRendahdiri o Sisip pikir
Pesimisme o Siar piker
Pikiran magis o Kontrol pikir
Pikiran curiga Lain lain :
Jelaskan:
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c. Bentuk pikir :
Realistik
Non realistik
Dereistik
Otistik Jelaskan:
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Diagnosa Keperawatan:
8. Kesadaran
Orientasi (waktu, tempat, orang) Jelaskan:
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Meninggi
Menurun:
Kesadaran berubah
Hipnosa
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Confusion
Sedasi
Stupor Jelaskan:
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Diagnosa Keperawatan:
9. Memori
Gangguan daya ingat jangka panjang ( > 1 bulan)
Gangguan dayaingat jangka menengah ( 24 jam - ≤ 1 bulan)
Gangguan daya ingat pendek (kurun waktu 10 detik sampai 15 menit)
Jelaskan:
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Diagnosa Keperawatan:
10. Tingkat Konsentrasi dan Berhitung
a. Konsentrasi
Mudah beralih
Tidak mampu berkonsentrasi
Jelaskan:
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b. Berhitung Jelaskan:
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Diagnosa Keperawatan:
11. Kemampuan Penilaian Gangguan ringan Gangguan bermakna
Jelaskan :
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Diagnosa Keperawatan:
12. Daya Tilik Diri
Mengingkari penyakit yang diderita
Menyalah kanhal-hal diluar dirinya Jelaskan:
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Diagnosa Keperawatan:
transportasi,
tempat tinggal.
Keuangan dan kebutuhan lainnya.
Jelaskan:
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2. Kegiatan Hidup Sehari hari
a. Perawatan diri
1) Mandi
Jelaskan :
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2) Berpakaian, berhias dan berdandan Jelaskan :
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3) Makan
Jelaskan :
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4) Toileting (BAK, BAB)
Jelaskan :
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Diagnosa Keperawatan:
b. Nutrisi
Berapa frekwensi makan dan frekwensi kudapan dalam sehari.
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Bagaimana nafsu makannya
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Bagaimana berat badannya.
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Diagnosa Keperawatan:
c. Tidur
1) Istirahat dan tidur
Tidur siang, lama : ____________ s/d _____________
Tidur malam, lama : _____________ s/d _____________
Aktifitas sebelum/sesudah tidur : __________ , _________
Jelaskan
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............................................................................................................................ 2) Gangguan
tidur
Insomnia
Hipersomnia
Parasomnia
Lain lain Jelaskan
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Diagnosa Keperawatan:
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3. Kemampuan lain lain
Mengantisipasi kebutuhan hidup
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Membuat keputusan berdasarkan keinginannya,
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Mengatur penggunaan obat dan melakukan pemeriksaan kesehatannya sendiri.
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Diagnosa Keperawatan:
4. Sistem Pendukung Ya Tidak
Keluarga
Terapis
Teman sejawat
Kelompok sosial
Jelaskan :
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Diagnosa Keperawatan:
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Masalah dengan dukungan kelompok,
spesifiknya Jelaskan :
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Masalah berhubungan dengan lingkungan,
spesifiknya Jelaskan :
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Masalah dengan pendidikan, spesifiknya
Jelaskan :
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Masalah dengan pekerjaan, spesifiknya Jelaskan :
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Masalah dengan perumahan, spesifiknya
Jelaskan :
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Masalah dengan ekonomi, spesifiknya Jelaskan :
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Masalah dengan pelayanan kesehatan,
spesifiknya Jelaskan :
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Masalah lainnya, spesifiknya Jelaskan :
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Diagnosa Keperawatan:
2. Terapi Medis
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DIAGNOSA
NO DATA
KEPERAWATAN
1. DS:
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DO:
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2. DS:
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DO:
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3. DS:
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DO:
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4. DS:
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DO:
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dst DS:
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DO:
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XV. POHON MASALAH
Lawang, ……………………….
Perawat yang mengkaji
____________________
NIM/NIRM: ..………….
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TINDAKAN KEPERAWATAN JIWA
Nama : Ruang : No CM : Unit :
Tanggal Diagnosa
No Tindakan Keperawatan Evaluasi Ttd
Jam Keperawatan
1
Keterangan :
Cara pendoku mentasian :
• Mengacu pada fasefase komunikasi terapeutik
• Pada kolom waktu diisi : Dx. Kep, Tanggal & jam tindakan Pada kolom
Tindakan Keperawatan diisi :
• Fase Oreantasi : Saat evaluasi/ validasi
• Fasekerja : Sesuai tindakan fase kerja
• Fase terminasi : Rencana Tindak Lanjut KolomEvaluasi:
• Evaluasi subyektif & Obyektif
• Berdasarkan respon subyektif, evaluasi obyektif
• Sesuai hasil evaluasi respon subyektif & obyektif pada fase terminasi
• A : Analisa , Sesuai dengan hasilin teraksi terakhir P : Planning ,
terdiridari P pasien dan P perawat
• P pasien : berdasarkan hasil rencana tindak lanjut pada fase terminasi
• P perawat : berdasarkan hasil kontrak yang akan datang pada fase
terminasi
1