FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

Ruangan Rawat _____________________ Tanggal Dirawat _____________________

A. IDENTITAS KLIEN
1. Inisial :_____________________(L/P)
2. Umur :_____________________
3. Pendidikan : _____________________
4. Pekerjaan : ____________________
5. Informan : _____________________
6. Status perkawinan : __________________
7. No.RMK : _____________________
8. Tanggal Pengkajian : _____________________
9. Diagnosa Medis : _____________________

B. ALASAN MASUK
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C. KELUHAN / KEADAAN KLIEN SAAT INI

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D. FAKTOR PRESIPITASI
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E. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu ? Ya Tidak
2. Pengobatan sebelumnya Berhasil Kurang berhasil Tidak berhasil
3. Trauma Pelaku/Usia Korban/Usia Saksi/Usia
Aniaya fisik

Aniaya seksual

Penolakan

Kekerasan dalam keluarga

Tindakan kriminal
Jelaskan No. 1, 2, 3 :
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Masalah keperawatan:
 Gangguan pertumbuhan dan perkembangan
 Gangguan proses keluarga
 Respon pasca trauma
 Resiko perilaku kekerasan
 Berduka disfungsional

4. Adakah anggota keluarga yang mengalami gangguan jiwa Ya Tidak

Hubungan keluarga Gejala Riwayat pengobatan/perawaran
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____Masalah Keperawatan :
 Koping keluarga tidak efektif : ketidakmampuan
 Koping keluarga tidak efektif : Penurunan
 Koping keluarga : potensial pertumbuhan
5. Pengalaman masa lalu yang tidak menyenangkan
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Masalah Keperawatan :
 Gangguan pertumbuhan dan perkembangan
 Gangguan proses keluarga
 Respon pasca trauma

F. PEMERIKSAAN FISIK
1. Tanda vital : TD : __________ N : ________ R : _________ T : _______________
2. Ukur : TB : __________ BB : ________
3. Keluhan fisik : Ya Tidak
Jelaskan :
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Masalah Keperawatan :
 Resiko gangguan suhu tubuh  Kerusakan integritas kulit
 Defisit volume cairan  Kerusakan integritas
 Kelebihan volume cairan jaringan
 Resiko infeksi  gangguan eliminasi fases
 Gangguan nutrisi < dari kebutuhan  gangguan eliminasi urin
tubuh  perubahan membrane
 Gangguan nutrisi > dari kebutuhan mukosa oral
tubuh
 Gangguan menelan

G. PSIKOSOSIAL
1. Genogram
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Keterangan :
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Jelaskan :
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Masalah Keperawatan :
 Koping keluarga tidak efektif : ketidakmampuan
 Koping keluarga tidak efektif : penurunan
 Koping keluarga : potensial pertumbuhan

2. Konsep diri
a Gambaran diri : ____________________________________________________
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b Identitas : ____________________________________________________
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c Peran : ____________________________________________________
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d Ideal diri : ____________________________________________________
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 e Harga diri : ____________________________________________________
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Masalah Keperawatan :
 Gangguan citra tubuh
 Gangguan identitas pribadi
 Gangguan konsep diri
 Harga diri rendah

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 berbuhungan dengan orang Lain :
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Masalah Keperawatan :
 Hambatan komunikasi verbal
 Isolasi sosial
 Hambatan interaksi social
 Perubahan performa peran

4. Spiritual
a Nilai dan keyakinan : ______________________________________________________
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b Kegiatan ibadah : ______________________________________________________
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Masalah Keperawatan :
 Distress spiritual

H. STATUS MENTAL
1. Penampilan

Tidak rapi Penggunaan pakaian Cara berpakaian tidak seperti

 tidak sesuai biasanya
Penjelasan :
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Masalah Keperawatan :
 Defisit perawatan diri

2. Pembicaraan

Cepat Keras Gagap Inkoheren

Apatis Lambat Membisu Tidak mampu memulai

Pembicaraan

Loghorea Echolalia
Penjelasan :
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Masalah Keperawatan :
 Hambatan komunikasi verbal

3. Aktivitas Motorik:

Lesu Tegang Gelisah Agitasi

TIK Grimasen Tremor Kompulsif

Penjelasan :
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Masalah Keperawatan :
 Resiko cedera
 Intoleransi aktivitas
4. Alam perasaaan

Sedih Ketakutan Putus asa Khawatir Gembira berlebihan

Penjelasan :
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Masalah Keperawatan :
 Resiko cedera
 Ansietas
 Ketakutan
 Ketidakberdayaan
 Ketidakmampuan
 Resiko membahayakan diri sendiri

5. Afek

Datar Tumpul Labil Tidak sesuai

Penjelasan :
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Masalah Keperawatan :
 Resiko cedera
 Hambatan komunikasi
 perubahan performa peran
6. lnteraksi selama wawancara

bermusuhan Tidak kooperatif Mudah tersinggung

Kontak mata (-) Defensif Curiga

Penjelasan :
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Masalah Keperawatan :
 Hambatan komunikasi verbal  Isolasi sosial
 Hambatan interaksi sosial  Resiko perilaku kekerasan
 Resiko membahayakan diri sendiri  Perubahan performa peran

7. Persepsi

Pendengaran Penglihatan Perabaan

Pengecapan Penghidu
Penjelasan :
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Masalah Keperawatan :
 Gangguan sensoris / persepsi

8. Proses Pikir

sirkumtansial tangensial kehilangan asosiasi

flight of idea blocking pengulangan pembicaraan/persevarasi

Neologisme
Penjelasan :
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Masalah Keperawatan :
 Gangguan proses pikir
9. Isi Pikir

Obsesi Fobia Hipokondria

depersonalisasi ide yang terkait pikiran magis

Waham

Agama Somatik Kebesaran Curiga

nihilistic sisip pikir Siar pikir Kontrol pikir

Penjelasan :
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Masalah Keperawatan :
 Gangguan proses pikir

10. Tingkat kesadaran

 bingung sedasi stupor

Disorientasi

waktu tempat orang

Penjelasan :
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Masalah Keperawatan :
 Gangguan proses pikir
 Resiko cedera

11. Memori

Gangguan daya ingat jangka panjang gangguan daya ingat jangka pendek

gangguan daya ingat saat ini konfabulasi

Penjelasan :
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Masalah Keperawatan :
 Gangguan proses pikir

12. Tingkat konsentrasi dan berhitung

mudah beralih tidak mampu konsentrasi Tidak mampu berhitung sederhana

Penjelasan :
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Masalah Keperawatan :
 Gangguan proses pikir
 Isolasi sosial

13. Kemampuan penilaian

 Gangguan ringan gangguan bermakna
Penjelasan :
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Masalah Keperawatan :
 Gangguan proses pikir

14. Daya tilik diri

mengingkari penyakit yang diderita menyalahkan hal-hal diluar dirinya

Penjelasan :
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Masalah Keperawatan :
 Ketidak efektifan penatalaksanaan program terapeutik
 Ketidakpatuhan (resti)
 Gangguan proses piker

I. KEBUTUHAN PERSIAPAN PULANG

1. Makan

Bantuan minimal Bantuan total

Penjelasan :
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2. BAB/BAK

Bantuan minimal Bantual total

Penjelasan :
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3. Mandi

Bantuan minimal Bantuan total

Penjelasan :
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4. Berpakaian/berhias

Bantuan minimal Bantual total

Penjelasan :
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5. Istirahat dan tidur

Tidur siang lama : ………………….s/d…………………………

Tidur malam lama : …………………s/d…………………………

Kegiatan sebelum / sesudah tidur

Penjelasan :
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6. Penggunaan obat

Bantuan minimal Bantual total

Penjelasan :
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7. Pemeliharaan Kesehatan

Perawatan lanjutan Ya tidak

Perawatan pendukung Ya tidak

Penjelasan :
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8. Kegiatan di dalam rumah

Mempersiapkan makanan Ya tidak

Menjaga kerapihan rumah Ya tidak

Mencuci pakaian Ya tidak

Pengaturan keuangan Ya tidak

Penjelasan :
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9. Kegiatan di luar rumah

Belanja Ya tidak

Transportasi Ya tidak

Lain-lain Ya tidak
Penjelasan :
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Masalah Keperawatan :
 Gangguan pemeliharaan kesehatan
 Gangguan eliminasi
 Defisit perawatan diri
 Gangguan nutrisi
 Gangguan pola tidur
 Ketidak efektifan penatalaksanan program terafetik
 Ketidakpatuhan
 Konflik pengambilan keputusan

J. MEKANISME KOPING
Adaptif Maladaptif

Bicara dengan orang lain Minum alkohol

Mampu menyelesaikan masalah reaksi lambat/berlebih

Teknik relaksasi bekerja berlebihan

Aktivitas konstruktif menghindar

Olahraga mencederai diri

Lainnya _______________ Lainnya : __________________

Penjelasan :
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Masalah Keperawatan :
 gangguan penyesuaian diri
 koping individu tidak efektif

K. 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 pekerjaan, 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 :
 Gangguan pemeliharaan kesehatan
 Gangguan konsep diri
 Ketidak berdayaan
  Ketidak mampuan
 Konflik peran menjadi orang tua
 Sindrom stres akibat pindah

L. KURANG PENGETAHUAN TENTANG:

Penyakit jiwa system pendukung

Faktor presipitasi penyakit fisik

Koping obat-obatan

Lainnya :
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Masalah Keperawatan :
 Ketidakefektifan penatalaksanan program terapetik
 Ketidakpatuhan
 Defisit pengetahuan (uraikan)

M. ASPEK PENUNJANG
Diagnosa Medik :
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Hasil Laboratorium :
Pemeriksaan Hasil Nilai Rujukan Satuan
HEMATOLOGI
Hemoglobin 13,0 – 16,0 g/dl
Eritrosit 4,5 – 5,5 juta/µl
Leukosit 5,0 – 10,0 ribu/µl
Hematokrit 45 – 55 vol%
Trombosit 150 – 400 ribu/µl
HITUNG JENIS
 Gran% 50.0-70.0 ribu/µl
Limfosit% 25.0-40.0 ribu/µl
MID% 4.0-11.0 ribu/µl
KIMIA HATI
SGOT 0-46 U/l
SGPT 0-45 U/l
WIDAL
S.Typhi O
S.Typhi H
S.Parayphi A
S.Parayphi B
KIMIA GULA DARAH
Gula Darah Sewaktu < 200 mg/dl
KIMIA GINJAL
Ureum 10-50 mg/dl
Creatinin 0.7-1.4 mg/dl
LAIN-LAIN
HBsAg Negatif

Terapi Medik
NO Nama Obat Dosis Indikasi Efek Samping
1. Clozapine 100 mg Mengobati penderita 1. Pusing saat sedang duduk
(Antipsikotik) ½ - 0-1 skizofrenia yang tidak atau berdiri
bereaksi pada obat 2. Mual, Merasa panas dan
antipsikotik lain. berkeringat
Mengurangi gejala 3. Berat badan bertambah
psikosis pada penyakit namun nafsu makan
parkinson. berkurang
4. Mulut kering disertai
meningkatnya produksi air
liur
5. Sulit buang air
 6. Perubahan pada hasil tes
darah dan EKG.
2. Haloperidol 5 mg Meredakan gejala 1. Mulut terasa kering
(Antipsikotik) 2x1 skizofrenia dan 2. Perubahan berat badan
masalah perilaku, atau 3. Sakit kepala
emosional, serta 4. Sakit perut
masalah kejiwaan 5. Sulit buang air kecil
lainnya 6. Perubahan suasana hati
7. Masalah menstruasi
8. Pandangan buram
9. Gemetar
10. Konstipasi
11. Sulit tidur
12. Detak jantung berdebar
13. Payudara membesar
14. Hidung tersumbat
15. Perubahan kemampuan
seksual
3. Trihexypheridol 2 mg Meningkatkan kendali 1. Konstipasi
(Antimuskarinik) 3x2 otot dan mengurangi 2. Pusing
kekakuan. Mengobati 3. Sulit buang air kecil
efek samping 4. Mulut kering
extrapyramidal yang 5. Pandangan buram
tidak diinginkan akibat 6. Mual
obat tertentu.
Gangguan gerakan ini
termasuk kondisi-
kondisi seperti tremor,
gerakan wajah dan
tubuh yang tidak
terkendali.
4. Lodomer 5 mg Agitasi psikomotor 1. Hipertonia otot
2x1 pada kelainan tingkah 2. Gemetar
lak 3. Tidak bisa istirahat
4. Gerakan mata tak
terkoordinasi
5. Hipotesi ortostatik,
galaktore.
5. Chlorpromazine 100 mg obat yang termasuk  Mengantuk.
2x1 golongan antipsikotik  Pusing atau sakit kepala
fenotiazina yang  Pandangan kabur.
bekerja dengan  Mulut kering.
menstabilkan senyawa  Mual.
alami otak. Digunakan  Gemetaran.
untuk menangani
 Gelisah.
berbagai gangguan
 Perubahan berat badan.
mental, seperti
skizofrenia dan  Sulit tidur.
 gangguan psikosis yang  Perubahan emosional.
lainnya, perilaku  Penurunan gairah seks.
agresif yang  Payudara yang membesar.
membahayakan pasien  Gangguan menstruasi.
atau orang lain,  Detak jantung yang cepat.
kecemasan dan  Konstipasi atau diare
kegelisahan yang
 Sulit buang air kecil.
parah.
6. Abilify 100 mg  Untuk  Meningkatkan nafsu makan
pengobatan  Penambahan berat badan
skizofrenia akut  Sakit kepala,
pada orang dewasa  Agitasi atau gelisah
dan remaja.  Insomnia
 Untuk terapi  Ngantuk
pemeliharaan pasien
 Hidung tersumbat
skizofrenia dan
 Mual muntah
gangguan bipolar
untuk anak, remaja  Dispepsia
dan dewasa.  Sembelit
 Mania akut dan  Gelisah
episode campuran  Tremor,
dari gangguan  Kekakuan otot
bipolar pada anak,
remaja dan dewasa.

 Sebagai terapi
tambahan untuk
gangguan depresi.
 TERAPI MEDIK

Nama Klien : Dx. Medis :

No. MR : Ruangan :
Jam Pemberian Obat

Nama Obat Jam Jam Jam Dosis Indikasi Kontra Indikasi Efek Samping
07.00 13.00 19.00
N. ANALISA DATA
Data Maladaftif Masalah Keperawatan
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O. DAFTAR MASALAH KEPERAWATAN
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P. DIAGNOSA KEPERAWATAN
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Q. POHON MASALAH
R. TAHAP PENANGANAN KLIEN
1. Skor Kategori Klien : ..............................................................................................
2. Tahap Penanganan Fase : ..............................................................................................
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3. Tujuan Pengobatan : ..............................................................................................
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4. Pengkajian Keperawatan : ..............................................................................................
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5. Intervensi Keperawatan : ..............................................................................................
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6. Hasil yang Diharapkan : ..............................................................................................
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Banjarmasin, Desember 2017

Pelaksana Pengkajian

Stefani Andani, S. Kep