RUANGAN RAWAT ............................. TANGGAL DIRAWAT .............................................
I. IDENTITAS KLIEN
Inisial : ..............................(L/P) Tanggal Pengkajian : ..............................
Umur : .............................. RM No. : ..............................
Informan : ..................................................................................
II. ALASAN MASUK
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III. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu ? Ya Tidak
2. Pengobatan sebelumnya Berhasil Kurang Berhasil Tidak Berhasil
3. Pengalaman Pelaku Usia Korban Usia Saksi Usia
Aniaya fisik
Aniaya seksual
Penolakan
Kekerasan dalam keluarga
indakan kriminal
Jelaskan No. 1, 2, 3 : .............................................................................................
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Masalah Keperawatan : .............................................................................................
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4. Adakah anggota keluarga yang mengalami gangguan jiwa Ya Tidak
Hubungan keluarga
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............................................. Gejala
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.................................. Riwayat pengobatan/perawatan
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Masalah keperawatan : ......................................................................................................
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5. Pengalaman masa lalu yang tidak menyenangkan
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Masalah keperawatan : ...................................................................................................
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IV. FISIK
1. Tanda Vital : TD : ................... N : .................. S : ................... P : ..................
2. Ukur : TB : ....................BB : ....................
3. Keluhan Fisik Ya Tidak
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
V. PSIKOSOSIAL
1. Genogram
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
2. Konsep diri
a. Gambaran diri
b. Identitas
c. Peran
d. Ideal diri
e. Harga diri
Masalah keperawatan :
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3. Hubungan Sosial
a. Orang yang berarti : ....................................................................................................
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b. Peran serta dalam kegiatan kelompok / masyarakat :
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c. Hambatan dalam berhubungan dengan orang lain :
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Masalah keperawatan : ...................................................................................................
4. Spiritual
a. Nilai dari keyakinan :
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b. Kegiatan ibadah
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Masalah keperawatan : ...................................................................................................
GENOGRAM :
VI. STATUS MENTAL
1. Penampilan
Tidak Rapi Penggunaan pakaian Cara berbakaian tidak
tidak sesuai seperti biasanya
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
2. Pembicaraan
Cepat Keras Gagap Inkoberen
Apatis Lambat Membisu Tidak mampu
mulai pembicaraan
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
3. Aktivitas Motorik
Lesu Tegang Gelisah Agitasi
Tik Grimasing Tremor Kompulsif
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
4. Alam perasaan
Sedih Ketakutan Putus asa Khawatir Gembira
berlebihan
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
5. Afek
Datar Tumpul Labil Tidak ssesuai
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
6. Interaksi selama wawancara
Bermusuhan Tidak kooperatif Mudah tersinggung
Kontak mata Defensif Curiga
kurang
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
7. Persepsi
Halusinasi
Pendengaran Pengelihatan Perabaan
Pengecapan Pembauan
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
8. Proses Pikir
Sirkumstansial Tangensial Kehilangan asosiasi
Flight of ideas Blocking Penanggulangan pembicaraan/
perseverasi
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
9. Isi Pikir
Obsesi Fobia Hipokodria
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 Konfabulasi
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
12. Tingkat konsentrasi dan berhitung
Mudah beralih Tidak mampu Tidak mampu berhitung
berkonsentrasi sederhana
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
13. Kemampuan penilaian
Gangguan ringan Gangguan bermakna
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
14. Daya tilik diri
Mengingkari penyakit yang diberita Menyalahkan hal-hal diluar dirinya
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
VII. KEBUTUHAN PULANG
1. Kemampuan klien memenuhi / menyediakan kebutuhan :
Ya Tidak Ya Tidak Ya Tidak
Makanan
Pakaian Uang
Keamanan Transportasi
Perawatan Kes. Tempat tinggal
Jelaskan : ...................................................................................................
Masalah keperawatan : ...................................................................................................
2. Kegiatan hidup sehari-hari
a. Perawatan diri
Bantuan minimal Bantual
total Bantuan minimal Bantual
total
Mandi
BAK / BAB
Kebersihan Ganti pakaian
Makan
Jelaskan : .............................................................................................
Masalah keperawatan : .............................................................................................
b. Nutrisi
Ya Tidak
- Apakah anda puas dengan pola makan anda ?
- Apakah anda makan memisahkan diri ?
Jika Ya, jelaskan alasannya ? ......................................................................................
- Frekuensi makan sehari ........................ kali
- Frekuensi udapan sehari ........................ kali
Meningkat Menurun Berlebihan Sedikit-sedikit
- Nafsu makan
Meningkat Menurun
BB tertinggi ......... BB terendah
- Diet khusus : .............................................................................................
Jelaskan : .............................................................................................
Masalah keperawatan : .............................................................................................
c. Tidur
Ya Tidak
- Apakah ada masalah ?
- Apakah anda merasa segar setelah bangun tidur ?
- Apakah anda kebiasaan tidur siang ?
Lamanya .........jam
- Apakah yang menolong anda untuk tidur ?...........................................................
- Waktu tidur malam : Jam ......................... Waktu bangun jam ............................
- Sulit tidur Terbangun saat tidur
- Bangun terlalu pagi Gelisah saat tidur
- Semnabolisme Berbicara dalam tidur
Jelaskan : .............................................................................................
Masalah keperawatan : .............................................................................................
3. Kemampuan Klien dalam
- Mengantisipasi kebutuhan sendiri
- Membuat keputusan berdasarkan keinginan sendiri
- Mengatur penggunaan obat
- Melakukan pemeriksaan kesehatan (folow up)
Jelaskan : .............................................................................................
Masalah keperawatan : .............................................................................................
4. Klien memiliki sistem pendukung
Keluarga Teman sejawat
Profesional / terapis Kelompok sosial
Jelaskan : .............................................................................................
Masalah keperawatan : .............................................................................................
5. Apakah klien menikmati saat bekerja kegiatan yang menghasilkan atau hobi
Jelaskan : .............................................................................................
Masalah keperawatan : .............................................................................................
VIII. MEKANISME KOPING
Adaptif
Bicara dengan orang lain
Mampu menyelesaikan masalah
Teknik reloksasi
Aktifitas konstruksi
Olah raga
lainnya Maladatif
Minum Alkohol
Reaksi lambat / berlebihan
Bekerja berlebihan
Menghindar
Mencederai diri
Lainnya
Masalah keperawatan : .............................................................................................
IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
Masalah dengan dukungan kelompok, spesifik ...........................................................................
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Masalah berhubungan dengan lingkungan, spesifik ....................................................................
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Masalah dengan pendidikan, spesifik..........................................................................................
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Masalah dengan perumahan, spesifik..........................................................................................
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Masalah ekonomi, spesifik...........................................................................................................
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Masalah dengan pelayanan kesehatan, spesifik............................................................................
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Masalah lainnya, spesifik.............................................................................................................
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Masalah keperawatan ...............................................................................................................
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X. PENGETAHUAN KURANG TENTANG
Penyakit jiwa
Faktor presipitasi
Koping Sistim pendukung
Penyakit fisik
Obat-obatan
Lainnya : .............................................................................................................................
XI. DATA LAIN-LAIN
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XII. ASPEK MEDIK
Diagnosa Medik : .................................................................................................................
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Terapi Medik : .................................................................................................................
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XIII. DAFTAR MASALAH KEPERAWARTAN
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XIV. DAFTAR DIAGNOSIS KEPERAWATAN
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