formulir pengkajian keperawatan kesesehatan jiwa
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FORMULIR PENGKAJIAN KEPERAWATAN KESESEHATAN JIWAA. PENGKAJIAN KEPERAWATAN KESESATAN JIWATanggal pengkajian..............................................
RUAING RAWAT:TGL. DIRAWAT:
I. IDENTITAS KLIENInisial:......................(P/L)Tanggal Pengkajian:......................Umur:......................RM.No:......................Informan:......................II. ALASAN MASUK.....................................................................................................................................................................................III. FAKTOR PREDISPOSISI1. Pemah mengalami gangguanjiwa di masa lalu? Ya Tidak2. Pengobatan sebelumnya Berhasil Kurang Berhasil Tidak Berhasil Pelaku/UsiaKorban/UsiaSaksi/Usia3. Aniaya fisik Aniaya seksual Penolakan Kekerasan dalam keluarga Tindakan kriminalJelaskan nomor: 1,2,3 :........................................................................................................................................................................................................Masalah KeprawatanIV. FISIK1. Tanda vital: TD:.............. N:.................. S:...................... P:......................2. UKUR: TB:............... BB:....... Turun Naik: Tidak 3. Keluhan fisik: YaJelaskan:.........................................................................................................................Masalah Keperawatan :...............................................................................................V. PSIKOSIAL1. Genogram
2. Konsep diri :a. Citra tubuh:................................................................................................................................................................................................................b. Identitas diri:...........................................................................................................................................................................................................c. Peran:....................................................................................................................................................................................................................d. Ideal diri:...............................................................................................................................................................................................................e. Harga diri:...............................................................................................................................................................................................................Masalah keperawatan:.........................................................................................3. Hubungan Sosial: a. Orang yang berarti :........................................................................................................................b. Peran serta dalam kegiatan kelompok masyarakat :.....................................................................................................................................................................................................................................................c. Hambatan dalam berhubungan dengan orang lain :....................................................................................................................................................................................................................................................Masalah Keperawatan:.............................................................................................................................................................................................................................................................4. Spiritual:a. Nlai dan Keyakinan: ..................................................................................................b. Kegiatan ibadah:.....................................................................................................Masalah Keperawatan::.....................................................................VI. STATUS MENTAL1. Penampilan: Tidak rapi Penggunaan pakaian tidak sesuai Cara berpakaian tidak seperti biasanyaJelaskan:.................................................................................................Masalah Keperatan:.................................................................................................
2. Pembicaraan: Cepat Keras Gagap Inkoheren Apatis Lambat Membisu Tidak mampu memulaipembicaraanJelaskan:.................................................................................................Masalah Keperatan:................................................................................................
3. Aktivitas Motorik : Lesu Tegang Gelisah Agitasi Apitas Lambat Membisu Tidak mampu memulai pembicaanJelaskan:.................................................................................................Masalah Keperatan:.................................................................................................
4. AIam PerasaanSedih ketakutan puttut asa khawatir gembira berlebihanJelaskan:.................................................................................................Masalah Keperatan:.................................................................................................5. Efek Dasar Tumpul Labil Tidak sesuaiJelaskan:.................................................................................................Masalah Keperatan:.................................................................................................
6. Interaksi selama Wawancara Bermusuhan Tidak Kooperatif Mudah Tersinggung Kontak Mata Kurang Defensi CurigaJelaskan:.................................................................................................Masalah Keperatan:.................................................................................................
7. Persepsi : tidak ada halusinasi.Halusinasi Pendengaran Penglihatan Perabaan Pengecapan PenghiduJelaskan:.................................................................................................Masalah Keperatan:.................................................................................................
8. Proses Pikir: Sirkumstansial Tangensial Kehilangan asosiasi Flight of ideas Blocking PersevasiJelaskan:.................................................................................................Masalah Keperatan:.................................................................................................9. Isi Pikir Obsesi Fobia Hipokrondri Depersonalisasi Ide yang terkait Pikiran magisJelaskan:.................................................................................................Masalah Keperatan:.................................................................................................10. Tingkat Kesadaran : Conpos mentis. Bingung Sedasi StuporDisorientasi Waktu Tempat OrangJelaskan :.....................................................................................................Maslah Keperawatan:.....................................................................................................11. Memori. Gangguan daya ingat jangka panjang Gangguan daya ngat jangka pendek Gangguan daya ingat saat ini KonfabulasiJelaskan :.....................................................................................................Maslah Keperawatan:.....................................................................................................
12. Tingkat Konsentrasi dan Berhitung Mudah beralih Tidak mampu berkonsentrasi Tidak mampu berhitung sederhanaJelaskan :.....................................................................................................Maslah Keperawatan:.....................................................................................................13. Kemampuan Penilaian Gangguan ringan Gangguan bermaknaJelaskan :.....................................................................................................Maslah Keperawatan:.....................................................................................................14. Daya Tilik Diri Mengingkari penyakit yang diderita Menyalahkan hal-hal diluar dirinyaJelaskan :.....................................................................................................Maslah Keperawatan:.....................................................................................................
VII. KEBUTUHAN PERSIAPAN PULANG1. Makan Bantuan minimal Bantuan total2. BAB/BAK Bantuan minimal Bantuan total3. Mandi Bantuan minimal Bantuan total4. Berpakaian/Berhias Bantuan minimal Bantuan total5. Istirahat dan TidurTidur siang lama :___________s/d___________Tidur malam lama :___________s/d___________Aktivitas sebelum/sesudah tidur :___________s/d___________
6. Peengunaan obat : perlu bantuan minimal Bantuan minimal Bantuan total7. Pemeliharaan kesehatan :Ya TidakPerawatan LanjutSistem pendukung8. Aktivitas di dalam rumahYa TidakMempersiapkan makananMenjaga kerapian rumahMencuci pakaianPengaturan keuangan9. Aktivitas di luar rumah : berbelanja, tranportasi, bantuan minimalYa TidakBelanjaTranportasiLain-lainJelaskan :.....................................................................................................Maslah Keperawatan:.....................................................................................................VIII. MEKANISME KOPINGAdaftifMeladatifBerbicara dengan orang lain Minum alkoholMampumenyelesaikan maslahReaksi lamban/berlebihanTeknik relokasiBekerja BerlebihanAktivitas kontruksiMenghindarOlah ragaMencederai diriLainnya LainnyaJelaskan :.....................................................................................................Maslah Keperawatan:.....................................................................................................
IX. MASALAH PSIKOSIAL DAN LINGKUNGANMasalah dengan dukungan kelompok, uraikan...................................................................................................................................Masalah berhubungan dengan lingkungan, uraikan...................................................................................................................................Masalah dengan pendidikan, uraikan...................................................................................................................................Masalah dengan pekerjaan, uraikan...................................................................................................................................Masalah dengan ekonomi, uraikan...................................................................................................................................Masalah dengan pelayanan kesehatan, uraikan...................................................................................................................................Masalah lainnya, uraikan...................................................................................................................................Maslah Keperawatan:.....................................................................................................X. KURANG PENGETAHUAN TENTANGPenyakit jiwaSistem pendukungFaktor predisposisiPenyakit fisikKopingObat-obatanLainnyaMaslah Keperawatan:.....................................................................................................XI. ASPEK MEDIADiagnosa Medik:.........................................................................................................................................................................................................Therapi Medik:.........................................................................................................................................................................................................XII. ANALISA DATANODataMasalah Keperawatan
1.Subjectif :..............................................Objectif :..............................................
2.Subjectif :..............................................Objectif :..............................................
XIII. POHON MASALAH.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................XIV. DIAGNOSA KEPERAWATAN DAN PRIORITAS........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................