FORMAT PENGKAJIAN

KEPERAWATAN KESEHATAN JIWA

Ruang rawat : ................................. Tanggal

dirawat: .............................
A. IDENTITAS KLIEN
Nama : .............................. (L/P)
Umur : .............................. Tahun
No. CM : ..............................
Tanggal Masuk : ..............................

B. ALASAN MASUK/FAKTOR PRESIPITASI

..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
...

C. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu?

YA
TIDAK
2. Pengobatan sebelumnya?

Berhasil Tidak berhasil

Kurang berhasil
3. Trauma

Usia Pelaku Korban Saksi

Aniaya fisik ........... ........... ........... ...........
Aniaya seksual ........... ........... ........... ...........
Penolakan ........... ........... ........... ...........
Kekerasan dalam ........... ........... ........... ...........
keluarga
Tindakan kriminal ........... ........... ........... ...........
Jelaskan: ...........................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
........
4. Anggota keluarga yang gangguan jiwa
YA
TIDAK
Jika ada

1 Format Pengkajian keperawatan kesehatan jiwa

 Hubungan keluarga
: .......................................................................................................................
..............
Gejala
: .......................................................................................................................
....................................................................................................................................
...............
Riwayat pengobatan
: .......................................................................................................................
....................................................................................................................................
...............
5. Pengalaman masa lalu yang tidak menyenangkan
…………………………………………………………………………………….............................................
.....................................................................................................................................

D. PEMERIKSAAN FISIK
1. Tanda Vital
TD : ..................... mmHg
HR : ..................... kali / menit
S : ..................... oC
RR : ..................... kali / menit
2. Ukur
BB : ..................... Kg
TB : ..................... cm
3. Keluhan fisik
……………………………………………………………………………………………………………………………….
…………….......................................................................................................................

E. PSIKOSOSIAL
1. Genogram

Jelaskan :
....................................................................................................................................
....................................................................................................................................

2 Format Pengkajian keperawatan kesehatan jiwa

 ....................................................................................................................................
...

Konsep Diri:
a. Citra Tubuh :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

b. Identitas :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
c. Peran
: .......................................................................................................................
...............................................................................................................................
...............................................................................................................................
........
d. Ideal Diri
: .......................................................................................................................
...............................................................................................................................
...............................................................................................................................
........
e. Harga Diri
: .......................................................................................................................
...............................................................................................................................
...............................................................................................................................
........

2. Hubungan sosial
a. Orang yang berarti
...............................................................................................................................
b. Peran serta dalam kegiatan kelompok / masyarakat
……………………………………………………………………….....................................................
...............................................................................................................................
c. Hambatan dalam berhubungan dengan orang lain
……………………………………………………………………….....................................................
...............................................................................................................................

3. Spiritual
a. Nilai dan keyakinan

3 Format Pengkajian keperawatan kesehatan jiwa

 ...............................................................................................................................
...............................................................................................................................
b. Kegiatan ibadah
...............................................................................................................................
...............................................................................................................................

F. STATUS MENTAL
1. Penampilan
Bagaimana penampilan klien dalam hal berpakaian, mandi, toileting, dan
pemakaian sarana / prasarana atau instrumentasi dalam mendukung penampilan,
apakah klien:

Tidak rapi
Penggunaan pakaian tidak sesuai
Cara berpakaian tidak seperti biasanya
Jelaskan :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
............

2. Pembicaraan

Cepat Apatis
Keras Lambat
Gagap Membisu
Inkoherensi Tidak mampu memulai
pembicaraan
Jelaskan :
.......................................................................................................
.......................................................................................................
.......................................................................................................
..........................................................................................

3. Aktivitas motorik

Lesu Tik
Tegang Grimasem
Gelisah Tremor
Agitasi Kompulsif
Jelaskan :
.......................................................................................................
.......................................................................................................

4 Format Pengkajian keperawatan kesehatan jiwa

 .......................................................................................................
..........................................................................................

4. Alam perasaan

Sedih Khawatir
Ketakutan Gembira berlebihan
Putus asa

5. Afek

Datar Labil
Tumpul Tidak sesuai

6. Interaksi selama wawancara

Bermusuhan Kontak mata kurang

Tidak kooperatif Curiga
Mudah tersinggung

7. Persepsi - Sensorik
Halusinasi / Ilusi ?
Ada / Tidak ?

Pendengaran Pengecapan
Penglihatan Penghidu
Perabaan
Jelaskan
Data Subjektif
Isi Halusinasi : ...............................................................................................
...............................................................................................
...............................................................................................
Frekuensi : ...............................................................................................
Waktu : ...............................................................................................
Situasi saat muncul : ...............................................................................................
Respon pasien : ...............................................................................................
...............................................................................................
...............................................................................................
Data Objektif : ...............................................................................................
...............................................................................................
...............................................................................................

8. Isi pikir

5 Format Pengkajian keperawatan kesehatan jiwa

 Obesi Depersonalisasi
Phobia Ide yang terkait Waham :
Hipokondria Pikiran magis
Agama Nihilistik
Somatik Sisip pikir
Kebesaran Siar pikir
Curiga Kontrol pikir
Jelaskan :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

9. Proses pikir

Circumstansial Flight of idea

Tangensial Blocking
Kehilangan asosiasi Pengulangan pembicaraan /
perseverasi
Jelaskan :
....................................................................................................................
....................................................................................................................
..................................
10. Tingkat Kesadaran

Bingung Disorientasi waktu

Sedasi Disorientasi orang
Stupor Disorientasi tempat

11. Memori

Gangguan daya ingat Gangguan daya ingat saat ini

jangka panjang
Gangguan daya ingat Konfabulasi
jangka pendek
Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
...........

12. Tingkat konsentrasi dan berhitung

6 Format Pengkajian keperawatan kesehatan jiwa

 Mudah beralih
Tidak mampu berkonsentrasi
Tidak mampu berhitung sederhana
Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
............

13. Kemampuan penilaian

Gangguan ringan
Gangguan bermakna
Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
............

14. Daya Tilik Diri

Mengingkari penyakit yang diderita

Menyalahkan hal-hal di luar dirinya
Jelaskan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
............

G. KEBUTUHAN PERENCANAAN PULANG

1. Kemampuan klien memenuhi kebutuhan

Makanan Transportasi
Keamanan Tempat tinggal
Perawatan Kesehatan Uang
Pakaian
Jelaskan :
......................................................................................................................................
......................................................................................................................................
........

2. Kegiatan hidup sehari-hari

a. Perawatan diri

Mandi BAK / BAB

7 Format Pengkajian keperawatan kesehatan jiwa
 Kebersihan Ganti pakaian
Makan
Jelaskan :
.....................................................................................................................................
.....................................................................................................................................

Nutrisi
Apakah anda puas dengan pola makan anda?

Ya
Tidak
Frekuensi makan sehari : .......... kali
Frekuensi kedapan sehari : .......... kali
Nafsu makan :

Meningkat Berlebihan
Menurun Sedikit – sedikit
Berat badan :

Meningkat
Menurun
BB terendah : .......... Kg BB tertinggi : .......... Kg
Jelaskan :
.....................................................................................................................................
.....................................................................................................................................

b. Tidur
Apakah ada masalah tidur ? YA / TIDAK
Apakah merasa segar setelah bangun tidur ? YA / TIDAK
Apakah ada kebiasaan tidur siang? YA / TIDAK
Lama tidur siang : ........ Jam
Apa yang menolong tidur ? .................................................................................
Tidur malam jam : ............................WIB , berapa jam : ..................................
Apakah ada gangguan tidur ?

Sulit untuk tidur Terbangun saat tidur

Bangun terlalu pagi Gelisah saat tidur
Somnambulisme Berbicara saat tidur
Jelaskan :
.................................................................................................................................
.................................................................................................................................

c. Penggunaan Obat

Bantuan minimal Bantuan total

8 Format Pengkajian keperawatan kesehatan jiwa

 3. Pemeliharaan Kesehatan

Ya Tidak
Perawatan lanjutan
Sistem pendukung

4. Aktivitas di Dalam Rumah

Ya Tidak
Mempersiapkan makanan
Menjaga kerapian rumah
Mencuci pakaian

5. Aktivitas di Luar Rumah

Ya Tidak
Belanja
Transportasi
Lain-lain
Jelaskan :
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................

H. MEKANISME KOPING

Adaptif: Maladaptif:
Bicara dengan orang lain Minum alkohol
Mampu menyelesaikan masalah Reaksi lambat/berlebih
Teknik relokasi Berkerja berlebihan
Aktivitas konstruktif Menghindar
Olah raga Menciderai diri
Lainnya: ............................ Lainnya: ........................

I. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

Masalah dengan dukungan kelompok/keluarga, uraikan

....................................................................................................................
....................................................................................................................
Masalah berhubungan dengan lingkungan, uraikan
.....................................................................................................................
.....................................................................................................................
Masalah berhubungan dengan pendidikan, uraikan
.....................................................................................................................
.....................................................................................................................
Masalah berhubungan dengan pekerjaan, uraikan

9 Format Pengkajian keperawatan kesehatan jiwa

 .....................................................................................................................
.....................................................................................................................
Masalah berhubungan dengan perumahan, uraikan
.....................................................................................................................
.....................................................................................................................
Masalah berhubungan dengan ekonomi, uraikan
.....................................................................................................................
.....................................................................................................................
Masalah berhubungan dengan pelayanan kesehatan, uraikan
.....................................................................................................................
.....................................................................................................................
Masalah berhubungan dengan lainnya, uraikan
.....................................................................................................................
.....................................................................................................................

J. ASPEK MEDIS
Diagnosis medis : .....................................................................................................
Terapi medis : .....................................................................................................
.....................................................................................................

K. DIAGNOSIS KEPERAWATAN
1. .................................................................................................................................
2. .................................................................................................................................
3. .................................................................................................................................
4. .................................................................................................................................
5. .................................................................................................................................

, 20

Perawat

( __________________ )

10 Format Pengkajian keperawatan kesehatan jiwa