PENGKAJIAN KEPERAWATAN JIWA

I. IDENTITAS
1. Nama :......................................................................................................
2. Umur :......................................................................................................
3. Tgl Pengkajian :......................................................................................................
4. No Register :......................................................................................................
5. Alamat :......................................................................................................
6. Tgl Masuk :......................................................................................................
II. ALASAN MASUK
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III. FAKTOR PREDIPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu □ ya □ tidak
2. Pengobatan sebelumnya □ berhasil □ belum berhasil □ tidak berhasil
3. Trauma

Pelaku/usia Korban/usia Saksi/usia

Aniaya fisik

Aniaya fisik

Penolakan

Kekerasan dalam keluarga

Tindakan kriminal

Jelasakan no. 1, 2, 3, :

Masalah keperawatan :

4. Adakah anggota keluarga yang mengalami gangguan jiwa □ ya □ tidak

Hubungan keluarga:...................................,Gejala........................................................
Riwayat Pengobatan : ..................................................................................................
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5. Pengalaman masa lalu yang tidak menyenangkan
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IV. PEMERIKSAAN FISIK
1. Tanda Vital : TD: mmHg, HR: x/mnt, S: ºC, RR: x/mnt
2. Ukur : TB: cm, BB kg, □ naik □ turun
3. Keluhan Fisik : □ ya □ tidak
Bentuknya:....................................................................................................................
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Masalah Keperawatan : ................................................................................................
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V. PSIKOSOSIAL
1. Genogram

Keterangan:.................................................................................................................................
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Masalah
Keperawatan :..............................................................................................................................
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2. Konsep Diri
a. Citra
Tubuh : .................................................................................................................................
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b. Identitas : ..............................................................................................................................
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c. Peran : ...................................................................................................................................
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d. Ideal
Diri : .....................................................................................................................................
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e. Harga
Diri : .....................................................................................................................................
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Masalah
keperawatan : ........................................................................................................................
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 3. Hubungan Sosial
a. Orang Terdekat .......................................................................................................
b. Peran serta dalam kegiatan
kelompok : ............................................................................................................................
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Masalah
keperawatan : ........................................................................................................................
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4. Spiritual
a. Nilai dan
keyakinan : ...........................................................................................................................
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b. Kegiatan
ibadah : .................................................................................................................................
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Masalah
keperawatan : ........................................................................................................................
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VI. STATUS MENTAL
1. Penampilan : .................................................................................................................
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2. Pembicaraan : ...............................................................................................................
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3. Aktivitas motorik : .......................................................................................................
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4. Alam perasaan : ............................................................................................................
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5. Afek : ............................................................................................................................
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6. Interaksi selama wawancara : .......................................................................................
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7. Persepsi : ......................................................................................................................
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8. Proses pikir : .................................................................................................................
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9. Isi pikir : .......................................................................................................................
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 10. Tingkat kesadaran : ......................................................................................................
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11. Memori : .......................................................................................................................
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12. Tingkat kosentrasi dan berhitung : ...............................................................................
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13. Kemampuan penilaian : ................................................................................................
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14. Daya tilik diri : .............................................................................................................
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Masalah keperawatan : .......................................................................................................
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VII. KEBUTUHAN PERSIAPAN PULANG ( UNTUK DI RSJ )
1. Makan : ...............................................................................
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2. BAB/BAK : ...................................................................
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3. Mandi
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4. Berpakaian/ berhias
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5. Istirahat tidur
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6. Penggunaan obat
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7. Pemeliharaan kesehatan
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8. Aktifitas dirumah
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9. Aktifitas di luar rumah
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Masalah keperawatan :
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VIII. MEKANISME KOPING
Adaptif Maladaptif

□ Berbicara dengan orla □ Minum alkohol

 □ Mampu menyelesaikan Mslh
□ Teknik relokasi □ Reaksi lambat

□ Aktifitas konstruktif □ Bekerja berlebihani

□ Olah raga □ Menghindar

□ Lainnya □ Mencederai diri

□ Lainnya

Masalah keperawatan :
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IX. MASALAH PSIKOSOSIAL DN LINGKUNGAN :
Masalah dengan dukungan kelompok :
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Masalah dengan lingkungan :
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Masalah dengan Pendidikan :
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Masalah dengan Pekerjaan :
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Masalah dengan perumahan :
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Masalah dengan Ekonomi :
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Masalah dengan pelayanan Kesehatan :
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Masalah lainnya :
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Masalah keperawatan :
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X. KURANG PENGETAHUAN TENTANG:

□ Penyakit jiwa □ Faktor predisposisi
 □ Koping □ Sistem pendukung
□ Penyakit fisik □ Obat-obatan
□ Lainnya

XI. ASPEK PENUNJANG

Diagnosa medis :
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Terapi medis :
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Laboratorium :
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XII. DAFTAR MASALAH KEPERAWATAN

Data maladaptif Masalah keperawatan
XIII. DIAGNOSA KEPERAWATAN
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