Pengkajian

FORMAT PENGKAJIAN KEPERAWATAN JIWA I.

II.

III.

IDENTITAS 1. Nama :...................................................................................................... 2. Umur :...................................................................................................... 3. Tgl Pengkajian :...................................................................................................... 4. No Register :...................................................................................................... 5. Alamat :...................................................................................................... 6. Tgl Masuk :...................................................................................................... ALASAN MASUK ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. FAKTOR PREDIPOSISI 1. 2.

IV.

□ tidak Pengobatan sebelumnya □ berhasil □ belum berhasil □ tidak berhasil Adakah anggota keluarga yang mengalami gangguan jiwa □ ya □ tidak Pernah mengalami gangguan jiwa di masa lalu

ya

3. Hubungan keluarga:...................................,Gejala........................................................ Riwayat Pengobatan : .................................................................................................. ........................................................................................................................................... ....................................................................................................................................... ................................................................................................................................... 4. Pengalaman masa lalu yang tidak menyenangkan ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... Masalah Keperawatan : ....................................................................................................................................... ....................................................................................................................................... PEMERIKSAAN FISIK 1. Tanda Vital : TD: mmHg, HR: x/mnt, S: ºC, RR: x/mnt 2. Ukur

: TB:

□

1.

□

cm, BB

□

kg,

□ naik □ turun

3. Keluhan Fisik : ya tidak Bentuknya:.................................................................................................................... Masalah Keperawatan : ................................................................................................ ....................................................................................................................................... V. PSIKOSOSIAL Genogram

Keterangan:................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... Masalah Keperawatan :............................................................................................................... ....................................................................................................................................... ....................... 5. Konsep Diri a. Cirta Tubuh : ................................................................................................................... ................................................................................................................................. .............. b. Identitas : ............................................................................................... ................................................................................................................................. .................................. c. Peran : ................................................................................................... ................................................................................................................................. .............................. d. Ideal Diri : ....................................................................................................................... ................................................................................................................................. .......... e. Harga Diri : ....................................................................................................................... ................................................................................................................................. .......... Masalah keperawatan : ......................................................................................................... ................................................................................................................................. ........................ 6. Hubungan Sosial a. Orang Terdekat ....................................................................................................... b. Peran serta dalam kegiatan kelompok : ............................................................................................................................... ................................................................................................................................. .. Masalah keperawatan : ............................................................................................................................... ................................................................................................................................. .. 7. Spiritual a. Nilai dan keyakinan : ............................................................................................................................... ................................................................................................................................. ..

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

b. Kegiatan ibadah : ................................................................................................................... ................................................................................................................................. .............. Masalah keperawatan : ......................................................................................................... ................................................................................................................................. ......................... VI. STATUS MENTAL Penampilan : ................................................................................................................. ....................................................................................................................................... Pembicaraan : .............................................................................................................. ....................................................................................................................................... Aktivitas motorik : ....................................................................................................... ....................................................................................................................................... ....................................................................................................................................... Alam perasaan : ............................................................................................................ ....................................................................................................................................... ....................................................................................................................................... Afek : ............................................................................................................................ ....................................................................................................................................... ....................................................................................................................................... Interaksi selama wawancara : ....................................................................................... ....................................................................................................................................... ....................................................................................................................................... Persepsi : ...................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... Proses pikir : ................................................................................................................. ....................................................................................................................................... ....................................................................................................................................... Isi pikir : ....................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... Tingkat kesadaran : ...................................................................................................... ....................................................................................................................................... ....................................................................................................................................... Memori : ....................................................................................................................... ....................................................................................................................................... ....................................................................................................................................... Tingkat kosentrasi dan berhitung : ............................................................................... ....................................................................................................................................... ....................................................................................................................................... Kemampuan penilaian : ................................................................................................ ....................................................................................................................................... ............................................................................................................. ......................... Daya tilik diri : ............................................................................................................. ....................................................................................................................................... ....................................................................................................................................... Masalah keperawatan : .......................................................................................................

............................................................................................................................................. ............................................................................................................................................. VII. KEBUTUHAN PERSIAPAN PULANG 1. Makan : ................................................................. ........................ 2. BAB/BAK : ..................................................... ................................... 3. Mandi : ........................................................................................ 4. Berpakaian/ berhias : ........................................................................................ 5. Istirahat tidur : ........................................................................................ 6. Penggunaan obat : ........................................................................................ 7. Pemeliharaan kesehatan : ........................................................................................ 8. Aktifitas dirumah : ........................................................................................ 9. Aktifitas di luar rumah : ........................................................................................ Masalah keperawatan : ........................................................................................................................................... ........................................................................................................................................... VIII.

MEKANISME KOPING Adaptif

□ Berbicara dengan orla □ Mampu menyelesaikan Mslh □ Teknik relokasi □ Aktifitas konstruktif □ Olah raga □ Lainnya IX.

Maladaptif

□ Minum alkohol □ Reaksi lambat □ Bekerja berlebihani □ Menghindar □ Mencederai diri □ Lainnya

Masalah keperawatan : ............................................................................................................................................. ............................................................................................................................................. MASALAH PSIKOSOSIAL DAN LINGKUNGAN : Masalah dengan dukungan kelompok : ............................................................................................................................................. Masalah dengan lingkungan : ............................................................................................................................................. Masalah dengan Pendidikan : ............................................................................................................................................. Masalah dengan Pekerjaan : .............................................................................................................................................

X.

Masalah dengan perumahan : ............................................................................................................................................. Masalah dengan Ekonomi : ............................................................................................................................................. Masalah dengan pelayanan Kesehatan : ............................................................................................................................................. Masalah lainnya : ............................................................................................................................................. Masalah keperawatan : ............................................................................................................................................. ............................................................................................................................................. KURANG PENGETAHUAN TENTANG:

□ Penyakit jiwa □ Faktor predisposisi □ Koping □ Sistem pendukung □ Penyakit fisik □ Obat-obatan □ Lainnya XI.

ASPEK PENUNJANG Diagnosa medis : ............................................................................................................................................. ............................................................................................................................................. Terapi medis : ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. Laboratorium : ............................................................................................................................................. ............................................................................................................................................. XII. DAFTAR MASALAH KEPERAWATAN Data maladaptif Masalah keperawatan

1. 2. 3. 4. 5. 6.

............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ ....... ............................................................................ ..................................................... ............................................................................ ............................................................ ............................................................................ ............................................................ ....... ............................................................................ ..................................................... ............................................................................ ............................................................ ............................................................................ ............................................................ ....... ............................................................................ ..................................................... ............................................................................ ............................................................ ............................................................................ ............................................................ ....... ............................................................................ ..................................................... ............................................................................ ............................................................ ............................................................................ ............................................................ ....... ............................................................................ ..................................................... ............................................................................ ............................................................ ............................................................................ ............................................................ ....... ............................................................................ ..................................................... ............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ ............................................................................ ............................................................ XIII. DIAGNOSA KEPERAWATAN ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................ XIV. TAHAPAN PENANGANAN KLIEN Skor kategori : ..................................................................................................... ..................................................................................................... Tahap penganan fase : ................................................................................. .................. ................................................................................. .................. Tujuan pengobatan : ................................................................................. .................. ................................................................................ .................. Pengkajian keperawatan : ....................................................................................... ....... Intervensi keperawatan: .......................................................................................... ....... ................................................................................. Hasil yang diharapkan : ................................................................................. .......

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