Format Pengkajian Keperawatan Kesehatan Jiwa

Ruangan Rawat : _______________________________

Tanggal Dirawat : _______________________________

I. IDENTITAS KLIEN

Inisial : _____________________________ (L/P)

Tgl Pengkajian : _____________________________

Umur : _____________________________

RM No. : _____________________________

Informan : _____________________________

II. ALASAN MASUK

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III. FAKTOR PREDISPOSISI

1. Pernah mengalami gangguan jiwa di masa lalu?

⃝ Ya ⃝ Tidak
2. Pengobatan sebelumnya?

⃝ Berhasil ⃝ Kurang Berhasil ⃝ Tidak Berhasil

3. Peristiwa kehidupan yang penuh tekanan: Pelaku/Usia Korban/Usia Saksi/Usia

 Aniaya Fisik ⃝ ⃝ ⃝ ⃝ ⃝ ⃝
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  Aniaya Seksual ⃝ ⃝ ⃝ ⃝ ⃝ ⃝
 Penolakan ⃝ ⃝ ⃝ ⃝ ⃝ ⃝
 KDRT ⃝ ⃝ ⃝ ⃝ ⃝ ⃝
 Tindakan Kriminal ⃝ ⃝ ⃝ ⃝ ⃝ ⃝
Kesimpulan No. 1, 2, dan 3:

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DIAGNOSA KEPERAWATAN :

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4. Adakah anggota keluarga yang mengalami gangguan jiwa?

⃝ Ya ⃝ Tidak

Hubungan Klg Gejala Riwayat Pengobatan/Perawatan

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DIAGNOSA KEPERAWATAN :

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IV. FISIK
1. Tanda-tanda Vital :

TD : ____________mmHg Nadi : __________x/mnt

Suhu : ____________0C Pernafasan : __________x/mnt

2. Antropometri :

TB : ____________cm BB : __________Kg

3. Keluhan Fisik :

Penjelasan :

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V. PSIKOSOSIAL
1. Genogram
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2. Konsep Diri

a. Gambaran Diri/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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DIAGNOSA KEPERAWATAN :

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3. Hubungan Sosial

a. Orang yang berarti/SO :

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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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DIAGNOSA KEPERAWATAN :

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4. Spiritual
a. Nilai dan Keyakinan :

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b. Kegiatan Ibadah :

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DIAGNOSA KEPERAWATAN :

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VI. STATUS MENTAL

1. Penampilan

⃝ Tidak Rapi ⃝ Kotor

⃝ Cara berpakaian tidak sesuai
2. Pembicaraan

⃝ Cepat ⃝ Lambat ⃝ Keras ⃝ Pelan

⃝ Kurang ⃝ Membisu ⃝ Tertekan ⃝ Gagap
⃝ Tidak Jelas ⃝ Aksen Aneh
3. Aktivitas Motorik

⃝ Lesu ⃝ Tegang ⃝ Gelisah ⃝ Agitasi

⃝ Tik ⃝ Grimasen ⃝ Tremor ⃝ Kompulsif
4. Alam Perasaan

⃝ Sedih ⃝Takut ⃝ Putus Asa ⃝ Euforia ⃝ Cemas

5. Afek

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 ⃝ Datar ⃝ Labil ⃝ Tidak sesuai
6. Interaksi selama Wawancara

⃝ Bermusuhan ⃝ Tidak kooperatif ⃝ Mudah tersinggung

⃝ Berhati-hati ⃝ Tidak Peduli ⃝ Defensif
⃝ Curiga ⃝Menggoda

7. Persepsi

⃝ Halusinasi Pendengaran ⃝ Halusinasi Penglihatan

⃝ Halusinasi Perabaan ⃝ Halusinasi Pengecapan
⃝ Halusinasi Penghidu
8. Proses Pikir

⃝ Sirkumstansial ⃝ Flight of Ideas ⃝ Kehilangan Asosiasi

⃝ Neologism ⃝ Perseverasi ⃝ Tangensial
⃝ Blocking ⃝ Word Salad
9. Isi Pikir

⃝ Siar Pikir ⃝ Sisip pikir ⃝

Depersonalisasi
⃝ Hipokondriasis ⃝ Ide Referensi ⃝ Pikiran Magis
⃝ Nihilistik ⃝ Obsesi ⃝ Phobia
Waham :

⃝ Agama ⃝ Somatik ⃝ Kebesaran

⃝ Paranoid
10. Tingkat Kesadaran

⃝ Bingung ⃝ Sedasi ⃝ Stupor

Disorientasi :

⃝ Waktu ⃝ Tempat ⃝ Orang

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11. Memori

⃝ Gangguan daya ingat jangka panjang

⃝ Gangguan daya ingat jangka pendek
⃝ Gangguan daya ingat saat ini
⃝ Konfabulasi
12. Tingkat Konsentrasi & Berhitung

⃝ Tidak mampu berhitung cepat

⃝ Tidak mampu berhitung sederhana
⃝ Tidak mampu berhitung mundur
13. Informasi dan Intelegensi

⃝ Tinggi ⃝ Rendah ⃝ Tidak mampu menjelaskan

14. Membuat Keputusan

⃝ Konstruktif ⃝ Destruktif
⃝ Tidak mampu memahami fakta ⃝ Tidak mampu menyimpulkan
15. Daya Tilik Diri

⃝ Menerima penyakit yang diderita

⃝ Mengingkari penyakit yang diderita
⃝ Menyalahkan hal-hal diluar dirinya
DIAGNOSA KEPERAWATAN :

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VII. KEBUTUHAN PERSIAPAN PULANG
1. Makan
⃝ Mandiri ⃝ Bantuan Minimal ⃝ Bantuan Total

2. Toileting (BAB/BAK)
⃝ Mandiri ⃝ Bantuan Minimal ⃝ Bantuan Total

3. Personal Hygiene (Mandi/Cuci Rambut/Sikat Gigi/Gunting Kuku)

⃝ Mandiri ⃝ Bantuan Minimal ⃝ Bantuan Total

4. Berpakaian
⃝ Mandiri ⃝ Bantuan Minimal ⃝ Bantuan Total

5. Penggunaan Obat
⃝ Mandiri ⃝ Bantuan Minimal ⃝ Bantuan Total

VIII. MEKANISME KOPING

Adaptif: Maladaptif:
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IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
 Masalah klien saat ini:

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 Interaksi dalam keluarga:

⃝ Sering ⃝ Jarang ⃝ Harmonis ⃝ Kurang Harmonis

 Sistem pendukung yang dimiliki:

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 Faktor etnik dan budaya yang dianut:
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 Keterampilan komunikasi:
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 Stressor ekonomi:
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 Ketersediaan pangan dan tempat berlindung:

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 Kekuatan dan kompetensi:

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X. ASPEK MEDIK
 Diagnosa Medik:

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 Terapi Medik:
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