FORM ASKEPjiwa.doc

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FORMULIR PENGKAJIANA KEPERAWATAN KESEHATAN JIWA

RUANGAN 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

tidak berhasil

3. Penganiayaan

Pelaku/UsiaKorban/UsiaSaksi/Usia

a. Aniaya fisik

b. Aniaya seksual

c. Penolakand. Kekerasan dalam keluarga

e. Tindakan kriminal

Jelaskan No. 1, 2, 3

: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Masalah Keperawatan : _________________________________________________

4. Adakah anggota keluarga yang mengalami gangguan jiwa Ya Tidak

Hubungan keluargaGejalaRiwayat pengobatan/perawaran

_____________________________________________________ ____________________________________________________________________________ ___________________

Masalah Keperawatan : _________________________________________________________

5. Pengalaman masa lalu yang tidak menyenangkan

___________________________________________________________________

____________________________________________________________________________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Masalah Keperawatan ________________________________________________________________IV. FISIK1. Tanda vital: TD : __________ N : _______S : _____P : __________

2. Ukur

: TB : __________ BB : ________

3. Keluhan fisik: Ya

Tidak

Jelaskan

: ______________________________________________________________

Masalah keperawatan : ______________________________________________________________

V. PSIKOSOSIAL 1. GenogramJelaskan

: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Masalah Keperawatan: ___________________________________________________________2. Konsep diri a. Gambaran diri

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________b. Identitas

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________c. Peran

___________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________

d. Ideal diri

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

e. Harga diri

: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Masalah Keperawatan: ______________________________________________________________3. Hubungan Sosiala. Orang yang berarti

________________________________________________________________________________________________________________________________________________________________________________________

b. Peran serta dalam kegiatan kelompok / masyarakat

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________c. Hambatan dalam berbuhungan dengan orang Lain : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Masalah keperawatan:______________________________________________________________

4. Spiritual

a. Nilai dan keyakinan

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

b. Kegiatan ibadah :_______________________________________________________________

_________________________________________________________________

_________________________________________________________________

Masalah Keperawatan

VI. STATUS MENTAL1. Penampilan

Tidak rapi Penggunaan pakaianCara berpakaian tidak seperti

tidak sesuai

biasanya

Jelaskan: _________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Masalah Keperawatan :

_________________________________________________________________

2. Pembicaraan

Cepat

Keras

Gagap

Inkoheren

ApatisLambat Membisu

Tidak mampu memulai

pembicaraan

Jelaskan : _________________________________________________________________

________________________________________________________________

Masalah Keperawan : _________________________________________________________________3. Aktivitas Motorik:

Lesu

Tegang

Gelisah

Agitasi

Tik

Grimasen

Tremor

Kompulsif

Jelaskan

_________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________

Masalah Keperawatan : _________________________________________________________________

4. Alam perasaaan

Sedih Ketakutan Putus asa Khawatir Gembira berlebihan

Jelaskan : _________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Masalah Keperawatan _________________________________________________________________5. Afek

Datar

Tumpul

Labil

Tidak sesuai

Jelaskan _________________________________________________________________

_________________________________________________________________

_________________________________________________________________________________________________________________________________

Masalah Keperawatan : _________________________________________________________________

6. lnteraksi selama wawancara

bermusuhan

Tidak kooperatif

Mudah tersinggung

Kontak mata (-) Defensif

Curiga