PENGKAJIAN KEPERAWATAN

KESEHATAN JIWA
Ruang rawat : Tanggal dirawat :
IDENTITAS KLIEN
Inisial :
Umur :
Tahun No.RM :
ALASAN MASUK
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FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu?
Ya
Tidak
2. Pengobatan sebelumnya:
Berhasil
Kurang Berhasil
Tidak Berhasil
3. Trauma
Jenis trauma Usia Pelaku Korban Saksi
Aniaya Fisik
Aniaya Seksual
Penolakan
Kekerasan dalam
 Keluarga
Tindakan Kriminal
Jelaskan:
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Masalah Keperawatan :

4. Anggota keluarga yang gangguan jiwa?

Ada
Tidak ada
Kalau ada:
Hubungan Keluarga :
Gejala :
Riwayat Pengobatan :
Masalah Keperawatan :

5. Pengalaman masa lalu yang tidak menyenangkan:

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Masalah Keperawatan :

PEMERIKSAAN FISIK
TTV :
TD = mmHg N = x/menit
S = °C P = x/menit
BB = kg TB = cm
Keluhan Fisik:
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Masalah Keperawatan :
PSIKOSOSIAL
1. Genogram

Jelaskan :
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Masalah Keperawatan :
2. Konsep Diri
a. Citra tubuh :
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b. Identitas diri :
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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 :

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 berhubungan dengan orang lain :
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Masalah Keperawatan :
4. Spiritual
a. Nilai dan keyakinan :
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b. Kegiatan ibadah :
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Masalah Keperawatan :

STATUS MENTAL
1. Penampilan
Tidak rapi
Penggunaan pakaian tidak sesuai
Cara berpakaian tidak seperti biasanya
Jelaskan :
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Masalah Keperawatan :

2. Pembicaraan
Cepat
Keras
Gagap
Inkohorensi
Lambat
Membisu
Tidak mampu memulai pembicaraan
Jelaskan :
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Masalah Keperawatan :

3. Aktifitas Motorik
Lesu
Tegang
 Gelisah
Agitasi
Tik
Grimasem
Tremor
Kompulsif
Jelaskan :
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Masalah Keperawatan :

4. Alam Perasaan
Sedih
Ketakutan
Putus asa
Khawatir
Gembira berlebihan
Jelaskan :
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Masalah Keperawatan :

5. Afek
Datar
Tumpul
Labil
Tidak sesuai
Jelaskan :
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Masalah Keperawatan :
6. Interasksi Selama Wawancara
Bermusuhan
Tidak kooperatif
Mudah tersinggung
Kontak mata kurang
Defensive
Curiga

Jelaskan :
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Masalah Keperawatan :
7. Persepsi Halusinasi
Pendengaran
Penglihatan
Perabaan
Pengecapan
Penghidu/penciuman
Jelaskan :
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Masalah Keperawatan :
8. Isi pikir
Obsesi
Phobia
Hipokondria
Depersonalisasi
Ide yang terkait
Pikiran magis
Jelaskan :
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Masalah Keperawatan :

9. Waham
Agama
Somatic
Kebesaran
Curiga
Nihilistik
Sisip pikir
Siar pikir
Kontrol pikir
Jelaskan :
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Masalah Keperawatan :

10. Arus Pikir

Sirkumstansial
Tangensial
Kehilangan asosiasi
Flight of idea
v Blocking
Pengulangan pembicaraan/preservasi
Jelaskan :
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Masalah Keperawatan :

11. Tingkat Kesadaran

Bingung
Sedasi
Stupor
 Disorientasi waktu
Disorientasi orang
Disorientasi tempat
Jelaskan :
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Masalah Keperawatan :

12. Memori
Gangguan daya ingat jangka panjang
Gangguan daya ingat jangka pendek
Gangguan daya ingat saat ini
Konfabulasi
Jelaskan :
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Masalah Keperawatan :

13. Tingkat Konsentrasi dan Berhitung

Mudah beralih
Tidak mampu berkonsentrasi
Tidak mampu berhitung sederhana
Jelaskan :
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Masalah Keperawatan :

14. Kemampuan Penilaian

Gangguan ringan
Gangguan bermakna
Jelaskan :
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Masalah Keperawatan :

15. Daya Titik Diri

Mengingkari penyakit yang diderita
Menyalahkan hal-hal diluar dirinya
Jelaskan :
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Masalah Keperawatan :

KEBUTUHAN PERENCANAAN PULANG

1. Kemampuan Klien Memenuhi Kebutuhan
Kebutuhan Klien Ya Tidak
a. Makanan :
b. Keamanan :
c. Perawatan kesehatan :
d. Pakaian :
e. Transportasi :
f. Tempat tinggal :
g. Uang :
Jelaskan :
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Masalah Keperawatan :

2. Kegiatan Hidup Sehari-Hari

a. Perawatan Diri
Perawatan Diri BT BM
  Mandi
 Kebersihan
 Makan
 BAB/BAK
 Ganti pakaian
Jelaskan :
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Masalah Keperawatan :

b. Nutrisi
Apakah anda puas dengan pola makan anda?
Ya
Tidak
Apakah anda memisahkan diri?
Ya, jelaskan :
Tidak
Frekuensi makan sehari :
Frekuensi kudapan sehari :
Nafsu makan :
Meningkat
Menurun
Berlebihan
Sedikt-sedikit
BB terendah : kg
BB tertinggi : kg
Jelaskan :
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Masalah Keperawatan :

c. Tidur
1) Apakah ada masalah tidur?
2) Apakah merasa segar setelah bangun tidur?
3) Apakah ada kebiasaan tidur siang?
4) Lama tidur siang :
5) Apa yang menolong tidur?
6) Tidur malam jam : Bangun jam :
7) Apakah ada gangguan tidur?
Sulit untuk tidur
Bangun terlalu pagi
Somnabulisme
Terbangun saat tidur
Gelisah saat tidur
Berbicara saat tidur
Jelaskan :
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Masalah Keperawatan :

3. Kemampuan klien dalam Mengantisipasi kebutuhan sendiri

Ya
Tidak
4. Membuat keputusan berdasarkan keinginan sendiri
Ya
Tidak
5. Mengatur penggunaan obat
Ya
Tidak
6. Melakukan pemeriksaan kesehatan
Ya
Tidak
Jelaskan :
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Masalah Keperawatan :
Klien memiliki sistem pendukung
Keluarga: Ya : Tidak :
Terapis : Ya : Tidak :
Teman sejawat : Ya Tidak :
Kelompok sosial: Ya Tidak :
Jelaskan :
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Masalah Keperawatan :
Apakah klien menikmati saat bekerja, kegiatan produktif atau hobi?
Ya
Tidak
Jelaskan :
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Masalah Keperawatan :

MEKANISME KOPING
Adaptif Maladaptif
Bicara dengan orang lain :
Mampu menyelesaikan masalah :
Teknik relokasi :
Aktifitas konstruktif :
Olahraga :
Lainnya :
Minum alcohol :
Reaksi lambat/berlebih :
Bekerja berlebihan :
Menghindar :
Mencederai diri :
Lainnya:
Jelaskan :
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Masalah Keperawatan :

MASALAH PSIKOSOSIAL & LINGKUNGAN

Masalah dengan dukungan kelompok, uraikan:
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Masalah dengan pendidikan, uraikan:
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Masalah dengan pekerjaan, uraikan:
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Masalah dengan perumahan, uraikan:
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Masalah dengan ekonomi, uraikan:
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Masalah dengan pelayanan kesehatan, uraikan:
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Masalah lainnya, uraikan:
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Masalah Keperawatan:

KURANG PENGETAHUAN TENTANG

Penyakit jiwa :
Factor presipitasi :
Koping :
Sistem pendukung :
Penyakit fisik :
Obat-obatan :
:
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Lainnya :
Masalah Keperawatan :

ASPEK MEDIK
Diagnosis Medik :
Terapi medic :
 PENGKAJIAN KEPERAWATAN
MASALAH PSIKOSOSIAL

Ruang rawat : Tanggal dirawat :

IDENTITAS KLIEN
Inisial :
Umur :
No.RM :
ALASAN MASUK
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PEMERIKSAAN FISIK
TTV :
TD = mmHg
N = x/menit
S = °C
P = x/menit
1. Konsep Diri
a. Citra tubuh :
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b. Identitas diri :
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 c. Peran :
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d. Ideal diri :
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e. Harga diri :
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2. Hubungan Sosial
a. Orang yang berarti :
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b. Peran serta dalam kegiatan kelompok/masyarakat :
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c. Hambatan dalam berhubungan dengan orang lain :
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MEKANISME KOPING
Adaptif Maladaptif
Bicara dengan orang lain :
Mampu menyelesaikan masalah :
Teknik relokasi :
Aktifitas konstruktif :
Olahraga :
Lainnya : :
Minum alcohol :
Reaksi lambat/berlebih :
Bekerja berlebihan :
Menghindar :
Mencederai diri :
Lainnya:
Jelaskan :
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Masalah Keperawatan :
MASALAH PSIKOSOSIAL & LINGKUNGAN
Masalah dengan dukungan kelompok, uraikan
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Masalah dengan pendidikan, uraikan:
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Masalah dengan pekerjaan, uraikan:
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Masalah dengan perumahan, uraikan:
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Masalah dengan ekonomi, uraikan:
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Masalah dengan pelayanan kesehatan, uraikan:
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Masalah lainnya, uraikan :
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Masalah Keperawatan :

ASPEK MEDIK

 Diagnosis Medik :

 Terapi medik :