pengkajian keperawatan jiwa

FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA
RUMAH SAKIT JIWA PROVINSI SULAWESI TENGGARA

RUANG RAWAT :  ......................                     TANGGAL RAWAT :  ............................

I.             Identitas klien

Inisial                : ..........................                    tanggal pengkajian         : ......................

Umur                : ..........................                    RM. No                          : ......................

Informan           : ..........................

II.           ALASAN MASUK

......................................................................................................................................................................................................................................................................................................................................................

III.         FAKTOR PREDISPOSISI

1.     Perna Mengalami Gangguan Jiwa Masa Lalu ?      Ya                    Tidak

2.     Pengobatan Sebelumnya :          Berhasil               Kurang Berhasil          Tidak Berhasil

3.                                             Pelaku/Usia                     Korban/Usia                  Saksi/Usia

                                                                                    

Aniaya Fisik                                                

 

Aniaya Seksual                                                                                                               

Penolakan                           

Kekerasan Dalam Keluarga                                                                                             

Tindakan Kriminal               

Jelaskan No. 1.2.3 :

......................................................................................................................................................................................................................................................................

Masalah Keperawatan :

.....................................................................................................................................................................................................................................................................

4.     Adakah Anggota Keluarga Yang Mengalami Gangguan Jiwa           Ya                         Tidak

Hubungan Keluarga                                      Gejala                     Riwayat Penyakit

.....................................                 .................................         ...................................

.....................................                 .................................         ...................................

Masalah Keperawatan :

......................................................................................................................................................................................................................................................................

5.     Pengalaman Masa Lalu Yang Tidak Menyenangkan

......................................................................................................................................................................................................................................................................

Masalah Keperawatan :

......................................................................................................................................................................................................................................................................

IV.  FISIK

1.     Tanda Vital                    : TD:..........        N:..........      S:............        P:.............

2.     Ukur                             : TB:............       BB:............    

3.     Keluhan Fisik                 :              Ya                             Tidak

Jelaskan:
......................................................................................................................................................................................................................................................................

Masalah Keperawatan :
......................................................................................................................................................................................................................................................................

1.     Genogram        

            Masalah Keperawatan
            .........................................................................................................................................            .........................................................................................................................................

2.     Konsep Diri

a.     Gambaran Diri         :....................................................................................................
                              ....................................................................................................

b.     Identitas                  :....................................................................................................
                              ....................................................................................................

c.     Peran                      :....................................................................................................
                               ....................................................................................................

d.     Ideal Diri                 :....................................................................................................
                              ....................................................................................................

e.     Harga Diri               :....................................................................................................
                              ....................................................................................................

Masalah Keperawatan:

.................................................................................................................................................................................................................................................................................

3.     Hubungan Sosial:

a.     Orang Berarti           :....................................................................................................
                              ....................................................................................................

b.     Peran Serta Dalam Kegiatan Kelompok/Masyarakat :
...................................................................................................................................

c.     Hambatan Dalam Berhubungan Dengan Orang Lain  :

................................................................................................................................

Masalah Keperawatan :

..................................................................................................................................................................................................................................................................................

4.     Spritual:

a.     Nilai Dan Keyakinan:

......................................................................................................................................................................................................................................................................

b.     Kegiatan Ibadah:

......................................................................................................................................................................................................................................................................

Masalah Keperawatan:

.........................................................................................................................................

.........................................................................................................................................

V.    STATUS MENTAL

1.   Penampilan

       Tidak Rapi                           Penggunaan Pakaian                  Cara Perpakaian Tidak

                                                  Tidak Sesuai                              Seperti Biiasanya

Jelaskan:

........................................................................................................................................................................................................................................................................

Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

2.     Pembicaraan

       Cepat                      Keras                Gagap                Inkoheren

        Apatis                     Lambat             Membisu            Tidak Mampu Memulai                                                                                                Pembicaraan

Jelaskan :

........................................................................................................................................................................................................................................................................

Masalah Keperawatan:

...................................................................................................................................

Aktivitas Motorik
      Lesu                         Tegang             Gelisah               Apatis

      Tik                           Grimasen          Tremor              Kompulsif

Jelaskan:

........................................................................................................................................................................................................................................................................

3.   Alam Perasaan

      Sedih             Ketakutan            Putus Asa            Khawatir          Gembira Berlebihan

Jelaskan :

........................................................................................................................................................................................................................................................................

Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

4.   Afek

      Datar                       Tumpul             Labil                             Tidak Sesuai

Jelaskan:

........................................................................................................................................................................................................................................................................

Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

5.   Interaksi Selama Wawancara

      Bermusuhan                          Tidak Kooperatif                        Mudah Tersinggung

      Kontak Mata Kurang              Defensil                                     Curiga

Jelaskan:

........................................................................................................................................................................................................................................................................Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

6.   Persepsi

      Pendengaran                        Penglihatan                    Perabaan

      Pengecapan                         Penghidu

Jelaskan:

........................................................................................................................................................................................................................................................................

Masalah Keperawatan

........................................................................................................................................................................................................................................................................

7.   Proses Pikir

      Sirkumntasial                       Tangensial                     Kehilangan Asosiasi

      Fligt Of Ideas                       Blocking                        Pengulangan Pembicaraan                                                     /Perseverasi

Jelaskan:

........................................................................................................................................................................................................................................................................

Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

8.   Isi Pikir

      Obsesi                     Fobia                             Hipokondria

      Depersonalisasi        Ide Yang Terkait             Pikiran Magis

Jelaskan:

........................................................................................................................................................................................................................................................................

Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

Waham

      Agama                      Somatik                          Kebesaran                     Curiga

      Nihilistik                    Sisip Pikir                       Siar Pikir                       Kontrol Pikir

Jelaskan:

........................................................................................................................................................................................................................................................................

Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

9.   Tingkat Kesadaran

      Bingung                    Sedasi                            Stupor

Disorientasi

      Waktu                      Tempat                          Orang

Jelaskan:

........................................................................................................................................................................................................................................................................Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

10.  Memori

      Gangguan Daya Ingat Jangka Panjang              Gangguan Daya Ingat Jangka Pendek

      Gangguan Daya Ingat Saat Ini                         Konfabulasi

Jelaskan:

........................................................................................................................................................................................................................................................................

Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

11.  Tingkat Konsentrasi Dan Berhitung

      Mudah Beralih                       Tidak Mampu Berkosentrasi                     Tidak Mampu

                                                                                                       Berhitung Sederhana

Jelaskan:

........................................................................................................................................................................................................................................................................

Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

12.  Kemampuan Penilaian

       Gangguan Ringan                              Gangguan Bermakna

Jelaskan:

........................................................................................................................................................................................................................................................................

Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

13.  Daya Tilik Diri

        Mengingkari Penyakit Yang Diderita                  Menyalahkan Hal-Hal Didalam Dirinya

Jelaskan:

........................................................................................................................................................................................................................................................................

Masalah Keperawatan:

........................................................................................................................................................................................................................................................................

VI.  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.   Istrahat Dan Tidur

        Tidur Siang                 :........................................................................................

        Tidur Malam               :........................................................................................

         Kegiatan Sebelum Dan Sesudah Tidur :.................................................................

6.   Pengguan Obat

    Bantuan Minimal                           Bantuan Total

7.   Pemeliharaan Kesehatan

                                                                 Ya                    Tidak

     Perawatan Lanjutan                                                                              

     Sistem Pendukung                                                                     

8.   Kegiatan Didalam Rumah

                                                                 Ya                    Tidak

     Mempersepsikan Makanan                                                                     

     Menjaga Kerapian Rumah                                                                     

     Mencuci Pakaian                                                           

     Pengaturan Keuangan                                                    

9.   Kegiatan Diluar Rumah              

                                                                  Ya                   Tidak  

     Belanja                                                                          

     Transportasi                                                                 

     Lain-Lain                                                                                  

 

Jelaskan:
...................................................................................................................................................................................................................................................................

Masalah keperawatan:

....................................................................................................................................................................................................................................................................

VII.        MEKANISME KOPING      

Adaptif Maladaptif

     Bicara Dengan Orang Lain                       Minum Alkohol

     Mampu Menyelesaikan Masalah                Reaksi Lambat/Berlebih

     Teknik Relaksasi                                     Bekerja Berlebihan

     Aktivitas Konstruktif                                Menghindar           

     Olah Raga                                              Mencederai Diri                                                  Lainnya.....................................            Lainnya................................................

Masalah Keperawatan:

..........................................................................................................................................................................................................................................................                                   

VIII.      MASALAH PSIKOSOSIAL DAN LINGKUNGAN

  Masalah dengan dukungan kelompok, spesifik:

................................................................................................................................

                      Masalah berhubungan dnegan lingkungan,spesifik:
                     ................................................................................................................................

                       Masalah dengan pendidikan, spesifik:

                     ................................................................................................................................

                       Masalah dengan perumahan,spesifik:

                     ................................................................................................................................

                       Masalah ekonomi,spesifik:

                     ................................................................................................................................

                       Masalah dengan pelayanan kesehatan,spesifik:

                     ...............................................................................................................................

                       Lainnya Masalah,spesifik:

                     ...............................................................................................................................

                  Masalah keperawatan:

                  .................................................................................................................................
                  ..................................................................................................................................

IX.          PENGETAHUAN KURANG TENTANG:

      Penyakit Jiwa                                               Sistem Pendukung

      Faktor predisposisi                                       penyakit fisik

      Koping                                                       obat-obatan

      Lainnya................................................................................................................

Masalah keperawatan:

......................................................................................................................................................................................................................................................................

X.            ANALISA DATA

XI.          ASPEK MEDIK
Diagnosa Medik       :
Terapi Medik           :....................................................................................................

                         ....................................................................................................                   ...................................................................................................                     ....................................................................................................

XII.        DAFTAR MASALAH KEPERAWATAN

.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

XIII.      DAFTAR DIAGNOSA KEPERAWATAN

..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

                                                                              .......,..........,............

                                                                                      Perawat   

                                                                                                                               

    

                                                                  

ANALISA DATA

No	Data	Masalah
	Subjektif : Objektif :
	Subjektif : Objektif :