FORMAT
PENGKAJIAN KEPERAWATAN JIWA
Ruang Rawat :
Tanggal dirawat :
No RM :
A.
Identitas Klien
Nama
:………………………………………………….( L / P )
Umur
:…………th
Alamat :.................................................................................................
Pekerjaan :.................................................................................................
Informan :.................................................................................................
Tgl Pengkajian :.................................................................................................
Dx Medis :.................................................................................................
B.
Alasan Masuk dan Faktor
Presipitasi
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………....................................................................................................................................
C. Faktor
Predisposisi
1.
Pernah
mengalami gangguan jiwa 
di
masa lalu ?
Ya
Tidak
Bila ya jelaskan....................................................................................................................................
...................................................................................................................................................................
2.
Pengobatan
sebelumnya
Berhasil
Kurang
berhasil
Tidak berhasil
3.
Trauma
Usia Pelaku Korban
Saksi
Aniaya
fisik ……
……… ……… ……… ..............
Aniaya
seksual ………
……… ………
................
...............
Penolakan ……
……… ……… ……… ...............
Kekerasan dlm klg ……
……… ……… ……… ...............
Tindakan kriminal ……
……… ……… ……… ...............
Jelaskan
:………………………………………………………………………….....................................
……………………………………………………………………………………..
4.
Anggota
keluarga yang ganguan jiwa
Ada
Tidak
Jika ada :
Hubungan keluarga : ………………………………………………………….................................
Gejala :
…………………………………………………………..................................
Riwayat pengobatan :
…………………………………………………………...................................
4.
Pengalaman
masa lalu yang tidak menyenangkan ?
……………...…………………………….........................................................................................................
……………………………………………........................................................................................................
….…………………………………………......................................................................................................
…………………………………………….......................................................................................................
D. Pemeriksaan
Fisik
1.
Tanda
Vfital : TD……….mmHg HR………X/mt
S………. RR………...X/mt
2.
Ukur : BB………..Kg TB……….cm
3.
Keluhan fisik …………………………………………………..............................................................
……………………………………………………………………………………..............................................
...................................................................................................................................................................
……………………………………………………………………………………..............................................
E. Psikososial
1.
Genogram
:
Jelaskan
: ………………………………................................................................................................
…………………………………………….................................................................................................
…………………………………………….................................................................................................
……………………………………………..................................................................................................
2.
Konsep
Diri
a.
Citra
Tubuh : …………………………........................................................................................
..........................................................................................................................................................
b.
Identitas
:…………………………...........................................................................................
..........................................................................................................................................................
c.
Peran
: …………………………..........................................................................................
..........................................................................................................................................................
d.
Ideal
diri :.................................................................................................................................... .............…………………………........................................................................................................
e.
Harga
Diri : ..…………………………......................................................................................
........................................................................................................................................................
3.
Hubungan
sosial
a.
Orang
yang berarti ……………………....................................................................................
b.
Peran
serta dalam kegiatan kelompok/
masyarakat :
…………………………….....................................................................................
c.
Hambatan
dalam berhubungan dengan
orang lain : ………………………………....................................................................................
4.
Spiritual
a.
Nilai
dan keyakinan……………………......................................................................................
b.
Kegiatan
ibadah ….……………………........................................................................................
F. Status
Mental
1.
Penampilan
Rapi
Tidak rapi
Penggunaan pakaian tidak sesuai
Cara berpakaian
tidak seperti biasanya
Jelaskan…………………………….....................................................................................................
……………………………………...........................................................................................................
……………………………………..........................................................................................................
2.
Pembicaraan
|
Cepat
Keras
¨
  Gagap
¨
Inkoherensi
|
Apatis
Lambat
Membisu
Tidak mampu memulai pembicaraan
|
Jelaskan…………………………………………………………….................................................................
……………………………………………………………………….....................................................................
3.
Aktivitas motorik
|
¨
 Fleksibilitas serea
¨
 Tegang
¨
Gelisah
¨
Agitasi
¨
Automatisma
¨
Negativisme
|
 Tik
 Grimasem
Tremor
Kompulsif
 Common Automatisma
|
|
Jelaskan................................................................................................................
.................................................................................................................................
.................................................................................................................................
|
|
4.
Alam
perasaan
Sedih
Ketakutan
Putus
asa
Khawatir
Gembira
berlebihan
Jelaskan……………………………….......................................................................................................
………………………………………….........................................................................................................
………………………………………….........................................................................................................
…………………………………………...............................................................................
5.
Afek
Datar
Tumpul
Labil
Tidak
sesuai
Jelaskan :
……………………………………….......................................................................................................
………………………………………......................................................................................................
6.
Interaksi
selama wawancara
Bermusuhan
Tidak kooperatif
Mudah
tersinggung
Kontak
mata kurang
Curiga
Jelaskan:
………………………………………….....................................................................................................
…………………………………………......................................................................................................
7.
Persepsi
Halusinasi
/ Ilusi:
Pendengaran
Penglihatan
Perabaan
Pengecapan
Penghidu
Jelaskan :
……………………………………………………………………………..........................................................
……………………………………………………………………………..........................................................
8.
Proses pikir
a.
Isi
Pikir
|
Obsesi
Phobia
 Hipokondria
|
Depersonalisasi Isolasi sosial
Ide yang terkait Pesimisme
Pikiran magis Bunuh diri
|
Waham
:
|
 Agama
 Somatik
 Kebesaran
 Curiga
|
Nihilistik
 Sisip pikir
Siar pikir
 Kontrol pikir
|
Jelaskan :
…………………………………………………………….…........................................................
…………………………………………………………………...................................................
b.
Arus pikir
|
Sirkumstansial
 Tangensial
  Kehilangan asosiasi
Inkoheren
|
Flight of idea
Blocking
Pengulangan pembicaraan /
perseverasi
 Logorea
|
Jelaskan : ……………………………………..............................................................................................
…………………………………………….................................................................................................
9.
Tingkat
kesadaran
|
 Bingung
 Sedasi
Stupor
|
 Disorientasi
waktu
Disorientasi
orang
Disorientasi tempat
|
Jelaskan
:…………….……………………………………………………....................................................
…………………………………………………………………...................................................
10.
Memori
Gangguan
daya ingat jangka panjang
Gangguan daya
ingat jangka pendek
Gangguan
daya ingat saat ini
Konfabulasi
Jelaskan: ……………………………………………………………………………..............................
……………………………………………………………………………..................................................
11.
Tingkat
konsentrasi dan berhitung
Mudah
beralih
Tidak
mampu berkosentrasi
Tidak mampu berehitung sederhana
Jelaskan :…………………………………………………………………………….................................
……………………………………………………………………………....................................................
12.
Kemampuan
penilaian
Gangguan ringan
Gangguan bermakna
Jelaskan
…………………………………………………………….....................................................
.......…..…………………………………………………….…..................................................................
13.
Daya
titik diri
Mengingkari
penyakit yang diderita
Menyalahkan hal-hal diluar dirinya
Jelaskan :…………………………………...........................................................................................
……………………………………………….............................................................................................
……………………………………………….............................................................................................
G. Kebutuhan
Persiapan
Pulang
1.
Makan
Bantuan minimal Sebagian Bantuan total
2.
BAB/BAK
Bantuan minimal Sebagian Bantuan total
3.
Mandi
Bantuan
minimal Sebagian Bantuan total
4.
Berpakaian/
berhias
Bantuan
minimal Sebagian Bantuan total
5.
Istirahat
tidur
Tidur siang :lama _____________________s/d
__________________________
Tidur
malam :lama_____________________s/d
___________________________
Aktifitas
sebelum / sesudah
tidur:......................................................................
............................................................................................................................................
6.
Penggunaan
obat
Bantuan
minimal Sebagian Bantuan total
7.
Pemeliharaan
kesehatan
Ya Tidak
Perawatan Lanjutan
Sistem Pendukung
8.
Aktifitas
diluar rumah
Mempersiapkan makanan
Menjaga kerapian rumah
Mencuci Pakaian
9.
Aktifitas
di luar rumah
Belanja
Transportasi
Lain-lain
Jelaskan : …………………………………………………………………………….............................
…………………………………………………………………………….....................................................
H.
MEKANISME KOPING
Adaptif Maladaptif
Bicara dengan orang lain Minum
Alkohol
Mampu
menyelesaikan masalah Bekerja
berlebihan
Aktifitas
konstruktif Menghindar
Olah raga
Mencederai
diri
Lainnya
..................................................................
...................................................................................... Lainnya....................................... .......................................................
I.
MASALAH PSIKOSOSIAL DAN LINGKUNGAN
Masalah dengan dukungan kelompok
,uraikan :.....................................................................
.......................................................................................................................................................................
Masalah berhubungan dengan lingkungan,uraikan
:............................................................
.......................................................................................................................................................................
Masalah dengan pendidikan
,uraikan
:......................................................................................
.......................................................................................................................................................................
Masalah dengan pekerjaan,
uraikan
:...........................................................................................
.......................................................................................................................................................................
Masalah dengan perumahan, uraikan:.........................................................................................
.......................................................................................................................................................................
Masalah dengan ekonomi, uraikan
:.............................................................................................
.......................................................................................................................................................................
Masalah dengan pelayanan
kesehatan,uraikan :.....................................................................
.......................................................................................................................................................................
Masalah lainnya, uraikan
:.................................................................................................................
.......................................................................................................................................................................
J.
KURANG PENGETAHUAN TENTANG
Penyakit jiwa Sistem
pendukung
Faktor presipitasi Penyakit
fisik
Koping Obat-obatan
Lainnya:.....................................................................................................................................................................................................................................................................................................................................................
K. ASPEK MEDIK
Diagnosa Medik :......................................................................................................................................
Terapi Medik :.....................................................................................................................................
