PROGRAM PENDIDIKAN PROFESI NERS

STASE KEPERAWATAN JIWA

STIKes SURYA GLOBAL YOGYAKARTA

FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

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

I. IDENTITAS
Nama (Inisial) :
L/P :
Umur :
Alamat :
Pendidikan :
Agama :
No. RM :
Tgl Pengkajian :
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 :
Jenis Trauma Usia Pelaku Korban Saksi
Aniaya Fisik
Aniaya Seksual
Penolakan
Kekerasan dalam
keluarga
Tindakan kriminal
Lain-lain
 Jelaskan No 1,2,3 :
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Masalah keperawatan :
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4. Adakah anggota keluarga yang mengalami gangguan jiwa? □ada□tidak

ada
Bila ada hubungan keluarga
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Gejala : ...................................................................
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Riwayat pengobatan / perawatan
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Masalah keperawatan :
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5. Pengalaman masa lalu yang tidak menyenangkan?
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Masalah keperawatan :
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IV. PEMERIKSAAN FISIK
a. Tanda Vital : TD: .......... HR: .........S: .......... RR: .........

b. Ukur : TB: cm, BB: kg, □naik□turun

c. Keluhan Fisik : □ada□tidak ada
Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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V. PSIKOSOSIAL
1. Genogram

Keterangan:

Jelaskan :
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Masalah Keperawatan :
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2. Konsep Diri
a. Gambaran diri
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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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Masalah keperawatan :
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3. Hubungan Sosial
a. Orang yang berarti :
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b. Peran serta kegiatan kelompok / masyarakat :

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c. Hambatan dengan berhubungan dengan orang lain :
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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 :

□Tidak rapi
□Penggunaan pakaian tidah sesuai
□Cara berpakaian tidak seperti biasanya
□lain-lain
Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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2. Pembicaraan :

□Cepat □Keras □Gagap

□Inkoherensi □Apatis □Lambat
□Membisu □Tidak mampu memulai Berbicara □lain-lain
Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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3. AktivitasMotorik :

□Lesu □Tegang □Gelisah

□Agitasi □ TIK □Grimasen
□Tremor □Kompulsif □lain-lain
 Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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4. AlamPerasaan (emosi) :

□Sedih □Ketakutan □Putus asa

□Khawatir □Gembira □Lain-lain
Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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5. Afek :

□Datar □Tumpul □Labil

□Tidak sesuai □Lain-lain
Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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6. Interaksi selama wawancara :

□Bermusuhan □Tidak Kooperatif □Mudah

tersinggung

□Kontak mata kurang □Defensif □Curiga

 Jelaskan : .............................................................................................................
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Masalah keperawatan :
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7. Persepsi–Halusinasi :

□Pendengaran □Penglihatan □Perabaan

□Pengecapan □Penghidu
Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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8. Proses Pikir :

□Sirkumstansial □Tangensial □Kehilangan

Asosia

□Flight of Idea □Blocking □Perseverasi

Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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9. Isi Pikir :

□Obsesi □Fobia □Hipokondria

□Depersonalisasi □Ide yang terkait □Pikiranmagis

Jelaskan : .............................................................................................................
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Masalah keperawatan :
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10. Tingkat Kesadaran :

□Binggung □Sedasi □Stupor

Adakah Gangguan orientasi ( disorientasi ) :

□Waktu □Orang □Tempat

Jelaskan : .............................................................................................................
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Masalah keperawatan :
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11. Memori :

□Gangguan daya ingat jangka panjang

□Gangguan daya ingat jangka menengah
□Gangguan daya ingat jangka pendek
□Konfabulasi
 Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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12. Tingkat Konsentrasi dan Berhitung :

□Mudah beralih □Tidak mampu berkonsentrasi

□Tidak mampu berhitung sederhana □Lain-lain
Jelaskan : .............................................................................................................
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Masalah keperawatan :
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13. Kemampuan Penilaian :

□Gangguan ringan □Gangguan bermakna

□Lain-lain
Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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14. Daya Tilik Diri :

 □Mengingkari penyakit yang diderita
□Menyalahkan hal-hal diluar dirinya
□lain-lain
Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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VII.KEBUTUHAN PERSIAPAN PULANG
1. Kemampuan klien memenuhi kebutuhan:
Kemampuan memenuhi kebutuhan Ya Tidak
Mempersiapkan makanan
Menjaga kerapian rumah
Perawatan kesehatan
Mencuci pakaian
Pengaturan keuangan
Belanja
Transportasi
Lain-lain

Jelaskan: ..............................................................................................................
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Masalah keperawatan :
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2. Kegiatan hidup sehari-hari (ADL)

 a. Perawatan diri :
Kegiatan hidup sehari-hari Bantuan total Bantuan minimal
Mandi
Kebersihan
Makan
Buang air kecil / BAK
Buang air besar / BAB
Ganti pakaian

Jelaskan : .............................................................................................................
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Masalah keperawatan :
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b. Nutrisi :
 Apakah puas dengan pola makan?

□Puas □Tidak puas

 Apakah makan memisahkan diri?

□Ya □Tidak
 Frekuensi makan sehari : ..........x
 Nafsu makan :

□Meningkat □Menurun □Berlebihan □Sedikit

 Berat badan :

□Meningkat □Menurun
BB saat ini : ........Kg, BB terendah : .......Kg, BB tertinggi : ............Kg
Jelaskan : .............................................................................................................
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Masalah keperawatan :
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c. Istirahat dan tidur :
  Apakah ada masalah tidur ?

□Ada □Tidak ada

 Apakah merasa segar setelah bangun tidur ?

□Segar □Tidak segar

 Apakah ada kebiasaan tidur siang ?

□Ya , lamanya : .........jam □Tidak

 Apakah ada yang menolong anda mempermudah untuk tidur ?

 □Ada □Tidak ada

 Tidur malam jam : .........bangun jam : .........rata-rata tidur
malam : ........jam
 Apakah ada gangguan pola tidur ?

□Sulit untuk tidur □Samnambulisme □Gelisah saat tidur

□bangun terlalu pagi □Terbangun saat tidur □Berbicara saat
tidur Jelaskan
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Masalah keperawatan :
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3. Kemampuan klien dalam hal-hal berikut ini :
 Mengantisipasi kehidupan sehari-hari :

□Ya □Tidak
 Membuat keputusan berdasarkan keinginan sendiri :

□Ya □Tidak
 Mengatur penggunaan obat :

□Ya □Tidak
 Melakukan pemeriksaan kesehatan :
 Perawatan lanjutan □Ya □Tidak
Sistem pendukung □Ya □Tidak
Jelaskan : ............................................................................................................
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Masalah keperawatan :
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VIII. MEKANISME KOPING
Adaptif Maladaptif
Berbicara dengan orang lain Minum alkohol
Mampu menyelesaikan Reaksi lambat/berlebih
Masalah
Teknik relaksasi Bekerja berlebihan
Aktifitas konstruktif Menghindar dari orang lain
Olah raga Mencederai diri
Lain-lain Lain-lain

Jelaskan : .................................................................................................................
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Masalah keperawatan :
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IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN :

□Masalah dengan dukungan kelompok,

spesifiknya ................................................................................................................
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□Masalah berhubungan dengan lingkungan,

spesifiknya ................................................................................................................
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 □Masalah dengan Pendidikan,
spesifiknya ................................................................................................................

...................□Masalah dengan Pekerjaan,

spesifiknya ................................................................................................................

...................□Masalah dengan perumahan,

spesifiknya ................................................................................................................
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□Masalah dengan Ekonomi,

spesifiknya ................................................................................................................

...................□Masalah dengan pelayanan Kesehatan,

spesifiknya ................................................................................................................
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Masalah keperawatan :
X. KURANG PENGETAHUAN TENTANG :
Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang
kurang tentang suatu hal?

□Penyakit jiwa □Faktor presipitasi □Sistem pendukung

□Penyakit fisik □Koping □Obat-obatan
□lain-lain
Jelaskan : ......................................................................................................................
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Masalah keperawatan :
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XI. ASPEK MEDIS
 Diagnosa
medis : .......................................................................................................................
...........

Terapi medis :
No Nama Obat Dosis Rute Indikasi

Laboratorium :

No Pemeriksaan Nilai (Satuan) Nilai Normal Interpretasi

DATA FOKUS
DATA SUBYEKTIF DATA OBYEKTIF
XII.ANALISA DATA
No SYMPTOM ETIOLOGI PROBLEM
XIII. DAFTAR DIAGNOSA KEPERAWATAN (PRIORITAS)