I. IDENTITAS KLIEN
Nama : _________________ (L/P) Tanggal Pengkajian : __________________
Umur : _______________ RM No. : ______________
Informan : _________________
Aniaya fisik
Aniaya seksual
Penolakan
Tindakan kriminal
Jelaskan No. 1, 2, 3 :
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Masalah Keperawatan :
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IV. FISIK
1. Tanda vital : TD : __________ N : ________ S : _________ P : _______________
2. Ukur : TB : __________ BB : ________
Jelaskan : ______________________________________________________________
Masalah keperawatan : ______________________________________________________________
V. PSIKOSOSIAL
1. Genogram
Jelaskan : _______________________________________________________________
2. Konsep diri
a Gambaran diri : _______________________________________________________________
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b. Identitas : _______________________________________________________________
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c. Peran (role performance) : _______________________________________________________________
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d. Ideal diri : _______________________________________________________________
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e. Harga diri : _______________________________________________________________
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Masalah Keperawatan : _______________________________________________________________
3. Hubungan Sosial
a. Orang yang berarti : _______________________________________________________________
b. Peran serta dalam kegiatan kelompok / masyarakat : _______________________________________
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c. Hambatan dalam berbuhungan dengan orang Lain : ________________________________________
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Masalah keperawatan: ________________________________________________________________
4. Spiritual
a. Nilai dan keyakinan : _________________________________________________________________
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b. Kegiatan ibadah : _________________________________________________________________
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Masalah Keperawatan__________________________________________________________________________
VI. STATUS MENTAL
1. Penampilan
2. Pembicaraan
Loghorea Echolalia
Jelaskan :_______________________________________________________________________________
Masalah Keperawatan : _____________________________________________________________
3. Aktivitas Motorik:
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : _______________________________________________
4. Alam perasaaan
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : _______________________________________________
5. Afek
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : _______________________________________________
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
7. Persepsi : halusinasi
Pengecapan Penghidu
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
8. Proses Pikir
neologisme
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
9. Isi Pikir
Waham
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
Disorientasi
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
11. Memori
Gangguan daya ingat jangka panjang gangguan daya ingat jangka pendek
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
14. Daya tilik diri
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
1. Makan
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
2. BAB/BAK
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
3. Mandi
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
4. Berpakaian/berhias
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
6. Penggunaan obat
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
7. Pemeliharaan Kesehatan
Perawatan lanjutan Ya tidak
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
Belanja Ya tidak
Transportasi Ya tidak
Lain-lain Ya tidak
Jelaskan : __________________________________________________________________________
Masalah Keperawatan : ______________________________________________________________
Adaptif Maladaptif
Koping obat-obatan
Lainnya : ______________________________________________________________________
Analisa Data
Data Dx Keperawatan
Dst
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_______________________________________ ___________________________________
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Mahasiswa,
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CATATAN KEPERAWATAN KESEHATAN JIWA DI RSJ
Nama : RM No.: