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PENGKAJIAN

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. Adakah anggota keluarga yang mengalami gangguan jiwa □ ya □ tidak
Hubungan keluarga:...................................,Gejala........................................................
Riwayat Pengobatan : ..................................................................................................
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4. 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. Cirta
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
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
: ........................................................................................
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 □ Reaksi lambat
□ Teknik relokasi □ Bekerja berlebihani
□ Aktifitas konstruktif □ Menghindar
□ Olah raga □ Mencederai diri
□ Lainnya □ 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
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XIII. DIAGNOSA KEPERAWATAN


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XIV. TAHAPAN PENANGANAN KLIEN


1. Skor kategori : ................................................................................. .......
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2. Tahap penganan fase : ................................................................................. .......
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3. Tujuan pengobatan
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4. Intervensi keperawatan
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5. Hasil yang diharapkan: ................................................................................. .......
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