FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA DI MENUR - SURABAYA

STIKES PEMKAB JOMBANG

 

Ruang rawat         :                                     Tanggal Dirawat   :

I.         IDENTITAS KLIEN

Inisial         :                                (L / P)   Tanggal Pengkajian   :                           

Umur         :                                             RM No.                      :                           

Informan    :                                                                                                           

II.       ALASAN MASUK

                                                                                                                     

                                                                                                                     

III.     FAKTOR PREDISPOSISI

1.   Pernah mengalami gangguan jiwa di masa lalu ?       Ya           Tidak

2.   Pengobatan sebelumnya         Berhasil        Kurang berhasil        Tdk 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 Pengobatan/

              Perawatan

                                                                                                                          

                                                                                                                          

Masalah Keperawatan :                                                                                    

5.   Pengalaman masa lalu yang tidak menyenangkan

                                                                                                                         

                                                                                                                         

Masalah Keperawatan :                                                                                     

IV.     FISIK

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

2.   Ukur :                TB :                       BB :                            Turun             Naik

3.   Keluhan Fisik :                     Ya                         Tidak

Jelaskan :                                                                                                              

Masalah Keperawatan :                                                                                         

V.       PSIKOSOSIAL

1.   Genogram

Jelaskan :                                                                                                         

Masalah Keperawatan :                                                                                    

2.   Konsep diri :

a.     Citra tubuh :                                                                                                                                                                                                      

b.     Identitas       :                                                                                                                                                                                          

c.     Peran            :                                                                                                                                                                                          

d.     Ideal diri       :                                                                                                                                                                                          

e.     Harga diri     :                                                                                                                                                                                          

Masalah Keperawatan :                                                                                    

3.   Hubungan Sosial :

a.     Orang terdekat :                                                                                                                                                                                 

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

                             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                 Grimasen          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

6.   Interaksi selama wawancara

         Bermusuhan                      Tidak kooperatif           Mudah tersinggung

         Kontak mata kurang           Defensif                        Curia

Jelaskan :                                                                                                        

Masalah Keperawatan :                                                                                    

7.   Persepsi

Halusinasi

       Pendengaran                 Penglihatan                   Perabaan

       Pengecapan                             Penghidu

Jelaskan :                                                                                                        

Masalah Keperawatan :                                                                                    

8.   Proses Pikir

          Sirkumstansial           Tangensial            Kehilangan asosiasi

          Flight of ideas             Blocking               Pengulangan pembicaraan/

                                                                          Preservasi

Jelaskan :                                                                                                        

Masalah Keperawatan :                                                                                    

9.   Isi Pikir

            Obsesi                         Fobia                              Hipokondria

            Depersonalisasi          Ide yang terkait             Pikiran magis

Waham

            Agama               Somatik              Kebesaran              Curiga

            Nihilistik           Sisip pikir           Siar pikir                Kontrol pikir

Jelaskan :                                                                                                        

Masalah Keperawatan :                                                                                    

10.    Tingkat Kesadaran

              Bingung              Sedasi            Stupor

Disorientasi :

               Waktu                 Tempat           Orang

Jelaskan :                                                                                                        

Masalah Keperawatan :                                                                                    

11.    Memori

Gangguan daya ingat jangka panjang        Gangguan daya ingat jangka pendek

 

Gangguan daya ingat saat ini                     Konfabulasi

Jelaskan :                                                                                                        

Masalah Keperawatan :                                                                                    

12.    Tingkat Konsentrasi dan Berhitung

Mudah beralih           Tidak mampu                 Tidak mampu berhitung berkonsentrasi               sederhatan

13.    Kemampuan Penilaian

Gangguan ringan                    Gangguan bermakna

Jelaskan :                                                                                                        

Masalah Keperawatan :                                                                                    

14.    Daya tilik diri

Menginginkan penyakit yang diderita            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

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                               

            Aktivitas sebelum / sesudah tidur :                            s/d                    

6.   Penggunaan obat

            Bantuan Minimal                         Bantuan total

7.   Pemeliharaan kesehatan

Ya               Tidak

Perawatan Lanjutan

Sistem Pendukung

8.   Aktivitas di dalam rumah

Ya               Tidak

Mempersiapkan makanan

Menjaga kerapihan rumah

Mencuci pakaian

Pengaturan keuangan

9.   Aktivitas di luar rumah

Ya               Tidak

Belanja

Transportasi

Lain – lain

Jelaskan :                                                                                                        

Masalah Keperawatan :                                                                                    

VIII.   MEKANISME KOPING

Adaptif                                                        Maladaptif

          Bicara dengan orang lain                                       Minum alkohol

          Mampu menyelesaikan masalah                  Reaksi lambat / berlebih

          Teknik relokasi                                            Bekerja berlebihan

          Aktivitas konstruktif                                     Menghindar

          Olah raga                                                     Mencederai diri

          Lainnya                                                        Lainnya

Masalah Keperawatan :                                                                                         

IX.       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

                                                                                                                  

Masalah keperawatan :                                                                                      

X.         KURANG PENGETAHUAN TENTANG

            Penyakit jiwa                                    Sistem pendukung

            Faktor presipitasi                              Penyakit fisik

            Koping                                              Obat-obatan

            Lainnya :                                                                                                   

Masalah Keperawatan :                                                                                         

XI.       ASPEK MEDIK

Diagnosa medik    :                                                                                               

                                                                                                                              

Terapi medik         :                                                                                               

                                                                                                                              

                                                                                                                              

XII.     DAFTAR MASALAH KEPERAWATAN

                                                                                                                              

                                                                                                                              

                                                                                                                              

                                                                                                                              

                                                                                                                              

XIII.   DIAGNOSA KEPERAWATAN

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           

                                                         

Mahasiswa,