FORMAT PENGKAJIAN KEPERAWATAN JIWA DIAGNOSA RESIKO

ASUHAN KEPERAWATAN JIWA PADA ......... DENGAN ..................

PENGKAJIAN
I. IDENTITAS KLIEN
1. Nama :
2. Umur :
3. Jenis kelamin :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Tgl. Pengkajian :

II. KELUHAN UTAMA

III. PREDISPOSISI DAN PRESIPITASI

Predisposisi:
........................................................................................................................
........................................................................................................................
Presipitasi:
.....................................................................................................................
.....................................................................................................................

IV. FISIK
Tekanan Darah :
Respiratory Rate :
Heart Rate :
Berat Badan :
Gula Darah Sewaktu :
Keluhan fisik :
Riwayat penyakit :

V. PSIKOSOSIAL
A. Genogram

Jelaskan...........
 B. Konsep Diri
1. Gambaran diri
............................................................................................................
2. Identitas diri
...........................................................................................................
3. Peran
...........................................................................................................
4. Ideal diri
............................................................................................................
5. Harga diri
...........................................................................................................
C. Hubungan sosial
1. Orang yang berarti
............................................................................................................
2. Peran serta dalam kegiatan kelompok/masyarakat
............................................................................................................
3. Hambatan dalam berhubungan dengan orang lain
............................................................................................................
D. Spiritual
1. Nilai dan keyakinan
............................................................................................................
2. Kegiatan ibadah
............................................................................................................
VI. STATUS MENTAL
A. Penampilan
..................................................................................................................
B. Pembicaraan
..................................................................................................................
C. Aktifitas motorik
..................................................................................................................
D. Alam perasaan
..................................................................................................................
E. Afek
..................................................................................................................
F. Interaksi selama wawancara
..................................................................................................................
G. Persepsi
..................................................................................................................
H. Proses fikir
..................................................................................................................
 I. Isi fikir
..................................................................................................................
J. Waham
..................................................................................................................
K. Tingkat kesadaran
..................................................................................................................
L. Memori
..................................................................................................................
M. Tingkat konsentrasi dan berhitung
..................................................................................................................
N. Kemampuan penilaian
..................................................................................................................
O. Daya tilik diri
..................................................................................................................

VII. KEBUTUHAN DASAR MANUSIA

A. Makan
..................................................................................................................
B. BAB/BAK
..................................................................................................................
C. Mandi
..................................................................................................................
D. Berpakaian/berhias
.................................................................................................................
E. Istirahat Tidur
................................................................................................................
F. Penggunaan obat
..................................................................................................................
G. Pemeliharaan kesehatan
..................................................................................................................
H. Kegiatan didalam rumah
..................................................................................................................
I. Kegiatan di luar rumah
..................................................................................................................

VIII. PENGGUNAAN DAN PEMELIHARAAN KESEHATAN

........................................................................................................................
........................................................................................................................
.......................................................................................
 IX. MEKANISME KOPING
........................................................................................................................
.......................................................................................................................
X. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
.......................................................................................................................
.......................................................................................................................
XI. PENGETAHUAN KURANG TENTANG
......................................................................................................................

ANALISA DATA

No Data Masalah
1 DS:

DO:

INTERVENSI KEPERAWATAN

No Tgl/Waktu Diagnosa Keperawatan Intervensi Keperawatan

IMPLEMENTASI KEPERAWATAN

No Hari, Tgl, Waktu No Dx Implementasi Respon

S:

O:

EVALUASI

No Diagnosa Evaluasi Sumatif

S:
O:
A:
P: