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
TIDAK
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 tanda gejala

PK .....................................................................................................................................
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4. Anggota keluarga yang gangguan jiwa
YA
TIDAK
Jika ada

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 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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Masalah keperawatan:
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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Masalah kep:.........

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 : ...............................................................................................
Waktu : ...............................................................................................
Situasi saat muncul : ...............................................................................................
Respon pasien : ...............................................................................................
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Data Objektif : ...............................................................................................
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8. Isi pikir
Obsesi Depersonalisasi
Phobia Ide yang terkait Waham :
Hipokondria Pikiran magis

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 Agama Nihilistik

Somatik Sisip pikir

Kebesaran Siar pikir

Curiga Kontrol pikir

Jelaskan :
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9. Proses pikir

Circumstansial Flight of idea

Tangensial Blocking
Kehilangan asosiasi Pengulangan pembicaraan / perseverasi
Jelaskan :
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10. Tingkat Kesadaran

Bingung Disorientasi waktu

Sedasi Disorientasi orang
Stupor Disorientasi tempat

11. Memori

Gangguan daya ingat jangka Gangguan daya ingat saat ini

panjang
Gangguan daya ingat jangka Konfabulasi
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 / TIDAK
Apakah merasa segar setelah bangun tidur ? YA / TIDAK
Apakah ada kebiasaan tidur siang? YA / TIDAK
Lama tidur siang : ........ Jam
Apa yang menolong tidur ? .................................................................................
Tidur malam jam : ............................WIB , berapa jam : ..................................
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
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 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. SUMBER KOPING

Kemampuan individu menyelesaikan masalah, uraikan

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Kemampuan keluarga menyelesaikan masalah pasien, uraikan
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Kemampuan finansial keluarga untuk membantu perawatan pasien,
uraikan
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Pengalaman perawatan sebelumnya, uraikan
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J. ASPEK MEDIS
Diagnosis medis : .....................................................................................................
Terapi medis : .....................................................................................................
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K. DIAGNOSIS KEPERAWATAN
1. .................................................................................................................................
2. .................................................................................................................................
3. .................................................................................................................................
4. .................................................................................................................................
5. .................................................................................................................................

, 2020

Perawat

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10 Format Pengkajian keperawatan kesehatan jiwa