FORMAT PENGKAJIAN KEPERAWATAN JIWA

 

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 :.................................................................................................................

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J.        KURANG PENGETAHUAN TENTANG

 

Penyakit jiwa                                                                                  Sistem pendukung

 

Faktor presipitasi                                                                         Penyakit fisik

 

Koping                                                                                               Obat-obatan    

 

Lainnya:.....................................................................................................................................................................................................................................................................................................................................................

K.  ASPEK MEDIK

                Diagnosa Medik              :......................................................................................................................................

 

                Terapi Medik                    :.....................................................................................................................................