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

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Data Saat ini :
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III. FAKTOR PREDISPOSISI

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

C. Pernah melakukan/mengalami/menyaksikan:

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 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 : ..............................................................................................................................
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......

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

D. Adakah anggota keluarga yang pernah menderita gangguan jiwa

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

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

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 Nadi : ........................ x/menit
Pernapasan : ........................ x/menit
B. Badan :
Tinggi : ........................ Cm
Berat : ........................ Kg
IMT : .................... Kesimpulan : .......................................................
C. Keluhan fisik :
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Masalah Keperawatan : .................................................................................................

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

Jelaskan :
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B. Konsep diri
1. Gambaran
diri : ......................................................................................................................
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2. Identitas diri :
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3. Peran diri :
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 4. Ideal diri :
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5. Harga diri :
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Masalah
Keperawatan : ................................................................................................................
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C. Hubungan sosial :
1. Orang yang berarti :
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2. Peran serta dalam kegiatan kelompok/masyarakat :
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3. Hambatan dalam berhubungan dengan orang lain :
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Masalah
keperawatan :...................................................................................................
D. Spritual
1. Nilai dan keyakinan :
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2. Kegiatan ibadah :
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Masalah
keperawatan : ..................................................................................................
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.
VI. STATUS MENTAL

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 A. Penampilan
□ Tidak rapih □ Pakaian tidak sesuai □ Cara berpakaian tidak
seperti biasanya
Jelaskan : ...................................................................................................................
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B. Pembicaraan
□ Cepat □ Keras □ Gagap □ Apatis
□ Lambat □ Inkoheren □ Membisu □ Tidak mampu memulai
□ Perseverasi
Jelaskan :
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C. Aktivitas Motorik
□ Lesu □ Tegang □ Gelisah □ Agitasi
□ TIK □ Grimace □ Tremor □ Kompulsif
Jelaskan :
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D. Alam Perasaan
□ Sedih □ Ketakutan □ Putus asa
□ Khawatir □ Gembira berlebihan/euforia
Jelaskan :
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E. Afek
□ Datar □ Tumpul □ Labil □ Tidak sesuai
Jelaskan :
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F. Interaksi Selama Wawancara
□ Bermusuhan □ Tidak kooperatif □ Mudah tersinggung
□ Kontak mata kurang □ Defensif □ Curiga
Jelaskan :
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G. Persepsi : Halusinasi

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 □ Pendengaran □ Penglihatan □ Perabaan
□ Pengecapan □ Penghiduan
Jelaskan :
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H. Proses Pikir
□ Sirkumtansial □ Tangensial □ Kehilangan asosiasi
□ Flight of ideas □ Blocking
Jelaskan :
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I. Isi Pikir
□ Obsesi □ Fobia □ Hipokondria
□ Depersonalisasi □ Pikir Magis □ Ide terkait
Waham :
□ Agama □ Somatik □ Kebesaran
□ Curiga □ Nihilistik □ Sisip pikir
□ Siar pikir □ Kontrol pikir
Jelaskan :
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J. Tingkat Kesadaran
□ Bingung □ Sedasi □ Stupor
Disorientasi :
□ Waktu □ Tempat □ Orang
Jelaskan :
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K. Memori
□ Gangguan daya ingat jangka panjang
□ Perubahan proses pikir pendek
□ Gangguan daya ingat saat ini
□ Konfabulasi
Jelaskan :
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L. Tingkat Konsentrasi dan Berhitung

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 □ Mudah beralih
□ Tidak mampu berkonsentrasi
□ Tidak mampu berhitung sederhana
Jelaskan :
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M. Kemampuan Penilaian
□ Gangguan ringan □ Gangguan bermakna
Jelaskan :
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N. Daya Tilik Diri (Insight)
□ Mengingkari penyakit yang diderita
□ Menyalahkan hal-hal di luar dirinya
Jelaskan :
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Masalah keperawatan :
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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 :
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Masalah keperawatan : ..................................................................................................

VIII. KEBUTUHAN PERSIAPAN PULANG

Bantuan minimal Bantuan total

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 A. Makan □ □
B. BAB dan BAK □ □

C. Mandi □ □
D. Berpakaian dan berhias □ □
E. Penggunaan Obat □ □
F. Istirahat dan Tidur
□ Tidur
siang : ........................................................................................................................
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□ Tidur
malam : ......................................................................................................................
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□ Kegiatan sebelum/setelah
tidur : ..........................................................................................................................
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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 :
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Masalah keperawatan : ..................................................................................................

IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

□ Masalahdengandukungankelompok

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 □ Masalahdenganpendidikan

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□ Masalahdenganpekerjaan

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□ Masalahdenganperumahan

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□ Masalahdenganekonomi

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□ Masalahdenganpelayanankesehatan

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

Nama Obat/ Dosis untuk Farmakokinetik dan

Golongan Pasien farmakodinamik obat

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 Mahasiswa yang mengkaji

(_______________________)

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