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

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C. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu?
YA
TIDA
K
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:
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 4. Anggota keluarga yang gangguan jiwa
YA
TIDA
K
Jika ada
Hubungan keluarga :
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Gejala :
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Riwayat pengobatan :
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5. Pengalaman masa lalu yang tidak menyenangkan
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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
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E. PSIKOSOSIAL
1. Genogram
Jelaskan :
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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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2. Hubungan sosial
a. Orang yang berarti
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b. Peran serta dalam kegiatan kelompok / masyarakat
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c. Hambatan dalam berhubungan dengan orang lain
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3. Spiritual
a. Nilai dan keyakinan
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b. Kegiatan ibadah
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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 :
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2. Pembicaraan
Cepat Apatis
Keras Lambat
Gagap Membisu
Inkoherensi Tidak mampu
memulai pembicaraan
Jelaskan :
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3. Aktivitas motorik
Lesu Tik
Tegang Grimasem
Gelisah Tremor
Agitasi Kompulsif
Jelaskan :
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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 :
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Frekuensi :
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Waktu :
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Situasi saat muncul :
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Respon pasien :
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Data Objektif :
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8. Isi pikir
Obesi Depersonalisasi
Phobia Ide yang terkait
Hipokondria Pikiran magis
Waham :
Agama Nihilistik
Somatik Sisip pikir
Kebesaran Siar pikir
Curiga Kontrol pikir
Jelaskan : ..................................................................................................................
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9. Proses pikir

Circumstansial Flight of
Tangensial Blocking
Kehilangan asosiasi Pengulan
Jelaskan : ....................................................................................................................
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10. Tingkat Kesadaran
Bingung Disorientasi waktu
Sedasi Disorientasi orang
Stupor Disorientasi tempat

11. Memori

Gangguan daya ingat Gangguan daya ingat saat

jangka panjang ini
Gangguan daya ingat Konfabulasi
jangka pendek
Jelaskan :
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12. Tingkat konsentrasi dan berhitung

Mudah beralih
Tidak mampu berkonsentrasi
Tidak mampu berhitung
sederhana
Jelaskan :
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13. Kemampuan penilaian

Gangguan ringan
Gangguan bermakna
Jelaskan :
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14. Daya Tilik Diri

Mengingkari penyakit yang
diderita Menyalahkan hal-hal di
luar dirinya
Jelaskan :
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G. KEBUTUHAN PERENCANAAN PULANG

1. Kemampuan klien memenuhi kebutuhan
Makanan Transportasi
Keamanan Tempat tinggal
Perawatan Kesehatan Uang
 Pakaian
Jelaskan :
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2. Kegiatan hidup sehari-hari

a. Perawatan diri
Mandi BAK / BAB
Kebersihan Ganti pakaian
Makan
Jelaskan :
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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 :
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b. Tidur
Apakah ada masalah tidur ? YA /
TIDAKApakah merasa segar setelah bangun tidur ? YA /
TIDAKApakah ada kebiasaan tidur siang? YA /
TIDAK
 Lama tidur siang.............Jam
Apa yang menolong tidur ?
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Tidur malam jam : ............................WIB , berapa jam :
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Apakah ada gangguan tidur ?
Sulit untuk tidur Terbangun saat tidur
Bangun terlalu pagi Gelisah saat tidur
Somnambulisme Berbicara saat
tidur Jelaskan :
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c. Penggunaan Obat
Bantuan minimal Bantuan total

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 :
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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
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Masalah berhubungan dengan lingkungan, uraikan
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Masalah berhubungan dengan pendidikan, uraikan
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Masalah berhubungan dengan pekerjaan, uraikan
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Masalah berhubungan dengan perumahan, uraikan
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Masalah berhubungan dengan ekonomi, uraikan
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Masalah berhubungan dengan pelayanan kesehatan, uraikan
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Masalah berhubungan dengan lainnya, uraikan
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J. ASPEK MEDIS
Diagnosis medis :...................................................................................
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Terapi medis :.....................................................................................
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K. DIAGNOSIS KEPERAWATAN
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5. ...................................................................................................................
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