FORMAT PENGKAJIAN

PENGKAHAN KEPERAWATAN KESEHATAN JIWA DIENIT RAWAT INAP RS. Dr. H. MARZOEKI MAHDI
BOGOR

RAWAT :_____________ TANGGAL DIRAWAT : _____________ No RM :_____________

I. IDENTITAS KLIEN
Inisial :________________ (LP) Tanggal Pengkajian :_________________

Umur :________________ Pendidikan :__________________

Status Perkawinan :________________ Jumlah AnaK :__________________

Pekerjaan :________________ informan :__________________

Alamat :________________
II. ALASAN MASUK
________________________________________________________________________
________________________________________________________________________
III. FAKTOR PREDISPOSISI
1. Pernai mengalami gangguan jiwa di masa lalu? Ya TidaK
2. Pengobatan sebelumnya Berhasil KURANG BERHASil tidak berhasil

3. Pelaku/Usia Korban/Usia Saksi/Usia

Anaya fisik

Aniaya seksual

Penolakan

Kekerasan dalam keluarga

Tindakan kriminal

Jelaskan :_______________________________________________________________

________________________________________________________________________

Masalah Keperawatan: ____________________________________________________

________________________________________________________________________

1. Adakah anggota keluarga yang mengalami gangguan jiwa Ya Tidak

Hubungan keluarga GEJALA Riwayat Pengobatan/perawatan
________________ ___________________ ______________________________
________________ __________________ ______________________________
________________ ___________________ ______________________________
________________ ___________________ ______________________________
 Masalah keperawatan______________________________________________________
________________________________________________________________________
________________________________________________________________________

2. Pengalaman masa lalu yang tidak menyenangkan

____________________________________________________________________
____________________________________________________________________

Masalah keperawatan__________________________________________________
____________________________________________________________________
____________________________________________________________________

3. Pengalaman masa lalu ___________________________________________________

______________________________________________________________________
Masalah keperawatan ___________________________________________________
______________________________________________________________________

IV. FISIK
1. Tanda vital : TD :________________N: ________S:________P:__________
2. Ukur : TB :_________________________BB: ___________________
3. Keluhan fisik Ya Tidak
Jelaskan : _________________________________________________________
_________________________________________________________________
Masalah Keperawatan :______________________________________________
_________________________________________________________________
2. konsep diri :

a. gambaran konsep :____________________________________________________

b. identitas :____________________________________________________

c. peran :____________________________________________________

d. ideal diri :____________________________________________________

e. harga diri :____________________________________________________

Masalah keperawatan :_________________________________________________________

______________________________________________________________________________

3. Hubungan sosial :

a. orang yang berarti :

__________________________________________________________________________

b. peran serta dalam kegiatan kelompok/masyarakat :

__________________________________________________________________________

c. Hambatan dalam berhubungan dengan orang lain :

__________________________________________________________________________

Masalah keperawatan :________________________________________________________

___________________________________________________________________________

4. Spiritual :

a. nilai dan Keyakinan :_________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

b. kegiatan ibadah :___________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Masalah keperawatan : _______________________________________________________

__________________________________________________________________________
VI. STATUS MENTAL

1. Penampilan
Tidak rapi penggunaan pakaian cara berpakaian
Tidak sesuai seperti biasanya

Jelaskan:________________________________________________________________

_______________________________________________________________________

Masalah keperawatan: _____________________________________________________

_______________________________________________________________________

2. Pembicaraan
Cepat keras gagap inkoheren
Apatis lambat membisu tidak mampu memulai
Pembicaraan
Jelaskan :________________________________________________________________
_______________________________________________________________________
Masalah keperawatan :____________________________________________________
_______________________________________________________________________

3. Aktivitas Motorik
Lesu Tegang Gelisah Agitasi

Tik Grimase Tremor Kompulsif

Jelaskan :________________________________________________________________
_______________________________________________________________________
Masalah Keperawatan :____________________________________________________
_______________________________________________________________________

4. Alam Perasaan
Sedih Ketakutan putus asa khawatir
gembira
berlebihan
Jelaskan :_______________________________________________________________
_______________________________________________________________________
Masalah keperawatan :____________________________________________________

_______________________________________________________________________

5. Afek
Datar Tumpul Labil Tidak sesuai
 Jelaskan :________________________________________________________________
_______________________________________________________________________
Masalah Keperawatan :
_______________________________________________________________________
_______________________________________________________________________

6. Interaksi selama Wawancara

Bermusuhan Tidak Kooperatif Mudah Tersinggung
Kontak mata kurang Defensif Curiga

Jelaskan:________________________________________________________________
_______________________________________________________________________

Masalah Keperawatan:_____________________________________________________

_______________________________________________________________________

7. Persepsi
Halusinasi
Pendengaran penglihatan perabaan

Pengecapan penghidu

Jelaskan :________________________________________________________________
_______________________________________________________________________
Masalah Keperawatan :____________________________________________________
_______________________________________________________________________

8. Isi Pikir
Obsesi Fobia Hipokondria

Depersonalisasi Ide Yang Terkait Pikiran Magis

Waham

Agama somatik Kebesaran Curiga

Jelaskan :_____________________________________________________________

_____________________________________________________________________

Masalah Keperawatan :__________________________________________________

_____________________________________________________________________

9. Proses Pikir
 Sirkumtansial Tangensial Kehilangan Asosiasi

Flight of ideas Blocking Pengulangan perkantaan/persevarasi

Jelaskan : _______________________________________________________________
_______________________________________________________________________
Masalah Keperawatan :____________________________________________________
_______________________________________________________________________

10. Tingkat kesadaran

Bingung sedasi stupor
Disorientasi :
Waktu Tempat Orang

Jelaskan : _______________________________________________________________
_______________________________________________________________________
Masalah Keperawatan :____________________________________________________
_______________________________________________________________________

11. Memori
Gangguan daya Ingat jangka pendek Gangguan daya ingat jangka panjang
Gangguan daya ingat saat ini Konfabulasi

Jelaskan :Jelaskan :
______________________________________________________________
______________________________________________________________________

Masalah keperawatan:___________________________________________________
______________________________________________________________________

12. Tingkat Konsentrasi Dan Berhitung

Mudah Beralih Tidak mampu Berkonsentrasi Tidak Mampu berhitung Sederhana

Jelaskan :________________________________________________________________
_______________________________________________________________________
Masalah keperawatan:_____________________________________________________
_______________________________________________________________________

13. Kemampuan Penilaian

Gangguan Ringan Gangguan Bermakna

Jelaskan:________________________________________________________________
_______________________________________________________________________
Masalah Keperawatan :____________________________________________________
_______________________________________________________________________
 14. Daya tarik diri
Mengingkari penyakit yang di derita menyalahkan hal-hal diluar dirinya

Jelaskan :________________________________________________________________
_______________________________________________________________________

Masalah keperawatan :

_______________________________________________________________________
_______________________________________________________________________

VII. KEBUTUHAN PERSIAPAN PULANG

1. Makan
Bantuan minimal bantuan total
2. BAB/BAK
Bantuan minimal Bantuan Total

Jelaskan :______________________________________________________________
______________________________________________________________________
Masalah keperawatan :___________________________________________________
______________________________________________________________________

3. Mandi
Bantuan minimal Bantuan total

4. Berpakaian/berhias
Bantuan minimal Bantuan total

5. Istirahat dan Tidur

Tidur siang. Lama :....................................s/d................................................................
Tidur malam. Lama :.....................................s/d............................................................
Kegiatan sebelum / sesudah tidur

6. Penggunaan obat
Bantuan minimal bantuan total

7. Pemeliharaan kesehatan
Ya tidak
Perawatan lanjutan
Sistem pendukung

8. Kegiatan didalam rumah

Ya tidak
Mempersiapkan makanan
Menjaga kerapihan rumah
 Mencuci pakaian
Pengaturan keuangan

9. Kegiatan di luar Rumah

Ya Tidak
Belanja
Transportasi
Lain-lain
Jelaskan :________________________________________________________________
________________________________________________________________________

Masalah keperawatan :_____________________________________________________

________________________________________________________________________

VII. ASPEK MEDIK

Diagnosa Medik :______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Terapi medik :______________________________________________________________

______________________________________________________________

______________________________________________________________

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TGL DATA(subyektif dan obyektif Masalah keperawatan TTD
 POHON DIAGNOSA DAN Dx KEPERAWATAN

A. Pohon Diagnosa

B. Daftar Dx keperawatan berdasarkan prioritas

1. .........................................................................................................................................
2. .........................................................................................................................................
3. .........................................................................................................................................
4. .........................................................................................................................................
5. .........................................................................................................................................
6. .........................................................................................................................................
7. .........................................................................................................................................
9. .........................................................................................................................................
10. ........................................................................................................................................

C.
 RENCANA TINDAKAN KEPERAWATAN

Nama klien : .................................... Dx medis : .......................................

Ruangan : .................................... No. RM : .......................................

NO Dx Keperawatan Tujuan Rencana Tindakan Keperawatan

Kriteria Evaluasi Intervensi Rasionanl