FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

JURUSAN KEPERAWATAN
POLTEKKES KEMENKES BENGKULU

Nama Mahasiswa : ..............................................

NIM : ..............................................
Tahun Ajaran : ..............................................

RUANGAN RAWAT : ……………… TANGGAL DIRAWAT: ………………………..

I. IDENTITAS KLIEN
Inisial : ……………….. (L/P) Tanggal pengkajian : ………………..
Umur : ……………….. RM No. : ………………..

II. ALASAN MASUK:

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III. KONDISI SAAT INI:

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IV. FAKTOR PREDISPOSISI DAN PRESIPITASI

A. BIOLOGI
1. Fisik:
a. Tanda Vital : TD: ………….. mmHg N: ……… x/mnt S: …….0 C P: ……..x/mnt
b. Ukur : TB: ………….. cm BB: …….. kg
c. Keluhan fisik saat ini:......…………………………………………………………………………..
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2. Pernah mengalami gangguan jiwa sebelumnya:

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 Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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3. Jika pernah mengalami gangguan jiwa bagaimana pengobatan sebelumnya:

Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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4. Riwayat merokok:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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5. Riwayat alkohol:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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6. Riwayat NAPZA:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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7. Riwayat Jatuh/kecelakaan/trauma kepala:

Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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8. Riwayat sakit kronis:

Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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Kesimpulan Stressor dari Biologi: ..............................................................................................................

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B. PSIKILOGIS

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1. Konsep diri :
a. Gambaran diri : .........................................................................................................................
b. Identitas : .........................................................................................................................
c. Peran : .........................................................................................................................
d. Ideal diri : .........................................................................................................................
e. Harga diri : .........................................................................................................................
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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2. Pola asuh:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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3. Tugas perkembangan:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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4. Pelaku/ Usia Korban/Usia Saksi/ Usia
a. Aniaya fisik : ……. ……. ……. ……. ……. …….
b. Aniaya seksual : ……. ……. ……. ……. ……. …….
c. Penolakan : ……. ……. ……. ……. ……. …….
d. Kekerasan dalam keluarga : ……. ……. ……. ……. ……. …….
e. Tindakan kriminal : ……. ……. ……. ……. ……. …….
f. Bullying/intimidasi: ……. ……. ……. ……. ……. …….

Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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5. Pengalaman yang tidak menyenangkan:

Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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Kesimpulan Stressor dari Psikologis : ……................……………………………………………………

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C. SOSIALKULTURAL :

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1. Riwayat pendidikan:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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2. Riwayat Pekerjaan/ ekonomi:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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3. Riwayat spiritual/keyakinan/ibadah:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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4. Riwayat budaya:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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5. Riwayat pernikahan/keluarga/tempat tinggal:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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6. Riwayat pergaulan/pertemanan/bermasyarakat:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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7. Riwayat Hospitalisasi/ pelayanan kesehatan:
Predisposisi:..............................................................................................................................................
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Presipitasi:.................................................................................................................................................
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8. Orang yang berarti: ..................................................................................................................................
9. Adakah anggota keluarga yang mengalami gangguan jiwa:.....................................................................

10. Genogram :

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 = Laki-laki

= Perempuan

= Meninggal

= Klien

= Pisah

= Hidup bersama
= Garis keturunan
= Garis perkawinan

11. Pengambil keputusan dirumah: ................................................................................................................

12. Komunikasi dalam anggota keluarga: ......................................................................................................
13. Di rumah klien dekat dengan: .................................................................................................................

Kesimpulan Stressor dari Sosialkultural: ..................................................................................................

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V. PENILAIAN (RESPON) TERHADAP STRESSOR

STRESSOR KOGNITIF AFEKTIF FISIOLOGIS PRILAKU SOSIAL

VI. STATUS MENTAL

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1. Penampilan :
Tidak rapi Penggunaan pakaian Cara berpakaian tidak seperti
Tidak sesuai biasanya
Lainnya:....................................................................................................................................................
2. Pembicaraan :
Cepat Keras Gelisah Inkoheren
Apatis Lambat Membisu Tdk mampu
memulai
pembicaraan
Lainnya:....................................................................................................................................................
3. Aktivitas motorik :
Lesu Tegang Gelisah Agitasi
Tik Grimasen Tremor Kompulsif

Lainnya:....................................................................................................................................................
4. Alam perasaan :
Sedih Ketakutan Putus asa Khawatir Gembira berlebihan

Lainnya:....................................................................................................................................................
5. Afek :

Datar Tumpul Labil Tidak sesuai

Lainnya:....................................................................................................................................................
6. Interaksi selama wawancara :
Bermusuhan Tidak kooperatif Mudah tersinggung
Kontak mata (-) Defensif Curiga

Lainnya:....................................................................................................................................................
7. Masalah Persepsi :
Pendengaran Penglihatan Perabaan
Pengecapan Penghidu

Lainnya:....................................................................................................................................................
8. Proses pikir :
Sirkumtansial Tangensial Kehilangan asosiasi
Flight of idea Blocking Pengulangan pembicaraan/perseverasi

Lainnya:....................................................................................................................................................

9. Isi pikir :
Obsesi Fobia Hipokondria
Defersonalisasi ide yang terkait Pikiran magis

Waham

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 Agama Somatik Kebesaran Curiga
Nihilistic Sisip pikir Siar pikir Kontrol pikir

Lainnya:....................................................................................................................................................
10. Tingkat kesadaran:
Bingung Sedasi Stupor

Disorientasi
Waktu Tempat Orang

Lainnya:....................................................................................................................................................
11. Memori :
Gangguan daya ingat jangka panjang Gangguan daya ingat jk pendek
Gangguan daya ingat saat ini Konfabulasi

Lainnya:....................................................................................................................................................
12. Tingkat konsentrasi dan berhitung :
Mudah beralih Tidak mampu konsentrasi Tidak mampu berhitung
sederhana
Lainnya:....................................................................................................................................................
13. Kemampuan penilaian :
Gangguan ringan Gangguan bermakna

Lainnya:....................................................................................................................................................
14. Daya tilik diri :
Mengingkari penyakit yang diderita Menyalahkan hal-hal diluar dirinya

Lainnya:....................................................................................................................................................

VII. KEBUTUHAN SEHARI-HARI/ PERSIAPAN PULANG

1.Makan
Bantuan minimal Bantuan total

2.BAB / BAK
Bantuan minimal Bantuan total

3.Mandi
Bantuan minimal Bantuan total

4.Berpakian / berhias
Bantuan minimal Bantuan total

5.Istirahat dan tidur

Tidur siang, lama : …………………………………………………………………………

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 Tidur malam, lama : …………………………………………………………………………

6.Pengguanaan obat
Bantuan minimal Bantuan toal

7.Pemeliharaan kesehatan
Perawatan lanjutan Ya Tidak
Perawatan pendukung Ya Tidak

8.Kegiatan di dalam rumah

Mempersiapkan makanan Ya Tidak
Menjaga kerapihan rumah Ya Tidak
Mencuci pakaian √ Ya Tidak
Pengaturan keuangan Ya Tidak

9. Kegiatan di luar rumah

Belanja Ya Tidak
Transportasi Ya Tidak
Lain-lain Ya Tidak

VIII. MEKANISME KOPING

Adaptif Maladaptif
Bicara dengan orang lain Minum alkohol
Mampu menyelesaikan masalah Reaksi lambat/berlebih
Tehnik relaksasi Bekerja berlebihan
Aktivitas konstruktif Menghindar
Olahraga Mencederai diri
Lainnya : .................................. Lainnya: ..........................................

IX. PENGETAHUAN KURANG TENTANG

Penyakit jiwa System pendukung
Faktor presipitasi Penyakit fisik
Koping Obat-obatan
Lainnya : .....................................................................................................................

ANALISA DATA
DATA MASALAH

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X. ASPEK MEDIK

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 Diagnosa Medik : ………………………………………………………….................…………………..

Terapi Medik :
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POHON MASALAH

XI. DAFTAR DIAGNOSA KEPERAWATAN

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XII. KEMAMPUAN KEPERAWATAN YANG SUDAH DIMILIKI
DIAGNOSA KEPERAWATAN PERSONAL ABILITY

…………….., ………………. 2020

Mahasiswa,

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 INTERVENSI KEPERAWATAN

Nama pasien: Ruangan:

DIAGNOSA TUJUAN DAN
NO INTERVENSI
KEPERAWATAN KRITERIA HASIL

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 IMPLEMENTASI KEPERAWATAN
Nama perawat : Nama Klien : Ruangan :
IMPLEMENTASI TINDAKAN KEPERAWATAN EVALUASI (SOAP)
Tanggal : Jam:

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