FORMAT PENGKAJIAN

KEPERAWATAN KESEHATAN JIWA

Ruang rawat : ..........

A. IDENTITAS KLIEN

Tanggal dirawat: .............

Nama

Status Perkawinan

Jenis Kelamin

Suku

Umur

No. CM

Alamat

Tanggal masuk

Agama

Tanggal Pengkajian

Pendidikan
Pekerjaan

:
:

Sumber Informasi

B. ALASAN MASUK/FAKTOR PRESIPITASI

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C. FAKTOR PREDISPOSISI

1. Pernah mengalami gangguan jiwa di masa lalu?

Diagnosis keperawatan
Perubahan pertumbuhan
dan perkembangan
Berduka antisipasi
Berduka disfungsional
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Respon pasca trauma
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Sindroma trauma
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perkosaan
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Perilaku kekkerasan
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Risiko perilaku kekerasan:
(pada diri, orang lain,
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2. Pengobatan sebelumnya?
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3. Trauma
Aniaya fisik

Usia
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Pelaku
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Korban
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Aniaya seksual

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Penolakan

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Kekerasan dalam keluarga

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Saksi
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Tindakan kriminal

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Jelaskan : ........................................................................................
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4. Anggota keluarga yang gangguan jiwa
Diagnosis keperawatan
YA
TIDAK
Jika ada :

...
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Koping keluarga tidak efektif :

ketidakmampuan
Koping keluarga tidak efektif:
kompromi
Risiko perilaku kekerasan: (pada
diri, orang lain, lingkungan,
verbal)

Hubungan keluarga
: ................................................................................................
Gejala

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Riwayat pengobatan : .................................
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5. Pengalaman masa lalu yang tidak menyenangkan
Diagnosis keperawatan

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Perubahan pertumbuhan
dan perkembangan
Berduka antisipatif
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Berduka disfungsional
Respon pasca trauma
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Sindroma trauma paska
perkosaan

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D. PEMERIKSAAN FISIK
1. Tanda Vital :
Saat masuk RS : TD .....................mmHg
S

.................... oC

HR : .........kali / menit

RR : ......... kali / menit

Saat pengkajian : TD .....................mmHg HR : .........kali / menit

S

.................... oC

2. Ukur

RR : ......... kali / menit

Saat masuk RS : BB .......................... Kg

TB : ......... cm

Saat pengkajian : BB .......................... Kg

TB : ......... cm

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3. Keluhan fisik
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Diagnosis keperawatan
Risiko tinggi perubahan suhu
tubuh
Defisit volume cairan
Risiko tinggi terhadap infeksil
Ketidakseimbangan nutrisi:
kurang dari kebutuhan tubuh
Ketidakseimbangan nutrisi:
kurang dari kebutuhan tubuh

Perubahannutrisi potensial lebih

dari kebutuhan tubuh
Kerusakan integritas jaringan
Perubahan membran mukosa
oral
Kerusakan integritas kulit
Perubahan eliminasi feses
Perubahan pola eliminasi urin

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E. PSIKOSOSIAL
1. Genogram

Diagnosis keperawatan
Koping keluarga tidak efektif:
ketidakmampuan
Koping keluarg tidak efektif:
kompromi

Jelaskan : .....................................................................................................
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Konsep Diri:

Diagnosis keperawatan
Gangguan citra tubuh
a. Citra Tubuh
Gangguan identitas
: ........................................................................................................
pribadi
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Harga diri rendah kronis
Harga diri rendah
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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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2. Hubungan sosial

Diagnosis keperawatan
a. Orang yang berarti : ................................
Kerusakan komunikasi verbal
Kerusakan Interaksi sosial
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Isolasi sosial

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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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3. Spiritual
Diagnosis keperawatan
a. Nilai dan keyakinan ................................................
Distres spiritual

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b. Kegiatan
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F. STATUS MENTAL
1. Penampilan
Bagaimana penampilan klien dalam hal berpakaian, mandi, toileting, dan
pemakaian sarana /prasarana atau instrumentasi dalam mendukung
penampilan, apakah klien:
Tidak rapi

Diagnosis keperawatan
Penggunaan pakaian tidak sesuai

Defisit perawatan diri

Cara berpakaian tidak seperti biasanya (berpakaian dan berhias)

Jelaskan : ...............................................................
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2. Pembicaraan

Diagnosis keperawatan
Kerusakan komunikasi
Cepat
Apatis
verbal
Keras
Lambat

Gagap
Membisu
Inkoherensi
Tidak mampu memulai pembicaraan
Jelaskan : ........................................................................................................
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3.Aktivitas motorik
Diagnosis keperawatan
Risiko cidera
Lesu
Tik
Perilaku kekerasan
Tegang
Grimasem

Gelisah
Tremor
Agitasi
Kompulsif
Jelaskan : ......................................................................................................
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4.Alam perasaan

Diagnosis keperawatan
Risiko cidera
Sedih
Ansietas
Ketakutan
Ketakutan
Keputusasaan
Putus asa
Ketidakberdayaan
Khawatir
Risiko bunuh diri
Gembira berlebihan
Risiko tinggi membahayakan diri
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5.Afek
Datar

Diagnosis keperawatan

Risiko cidera
Kerusakan komunikasi verbal
Labil
Kerusakan interaksi sosial
Tidak sesuai
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Tumpul

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Interaksi selama wawancara

Diagnosis keperawatan
Kerusakan komunikasi verbal
Bermusuhan
Kerusakan interaksi sosial
Tidak kooperatif
Isolasi sosial
Risiko bunuh diri
Mudah tersinggung
Risiko tinggi membahayakan diri
Kontak mata kurang
Perilaku kekerasan
Curiga
Risiko perilaku kekerasan : (pada diri,
orang lain, lingkungan, verbal)
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6.Persepsi - Sensorik
Halusinasi/Ilusi? ADa / Tidak?
Pendengaran
Penglihatan
Perabaan
Pengecapan

Diagnosis keperawatan
Gangguan persepsi sensori:
Halusianasi
(pendengaran/penglihatan/pengecap
/penghidu/peraba)
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Penghidu
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7.Isi pikir
Obesi
Phobia
Hipokondria

Depersonalisasi
Ide yang terkait
Pikiran magis

Agama
Nihilistik
Somatik
Sisip pikir
Kebesaran
Siar pikir
Curiga
Kontrol pikir
Jelaskan : .....................................................
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Diagnosis keperawatan
Waham :
Perubahan proses pikir
Kerusakan komunikasi
verbal

8.Proses pikir
Circumstansial
Tangensial
Kehilangan asosiasi

Flight of idea
Blocking
Pengulangan pembicaraan /
perseverasi
Jelaskan : ...................................................................................................
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9.Tingkat Kesadaran

Diagnosis
keperawatan

Bingung

Disorientasi waktu

Sedasi

Disorientasi orang

Stupor
Disorientasi
Lingkungan
Jelaskan

Disorientasi tempat

Risiko cidera
Gangguan proses

10. Memori
Gangguan daya ingat jangka panjang
Gangguan daya ingat jangka pendek
Gangguan daya ingat saat ini
Konfabulasi

Diagnosis keperawatan
Perubahan proses pikir

Jelaskan : ..................................................................................
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11. Tingkat konsentrasi dan berhitung

Mudah beralih
Tidak mampu berkonsentrasi

Diagnosis keperawatan
Perubahan proses pikir

Tidak mampu berhitung sederhana

Jelaskan : ................................................................................
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12. Kemampuan penilaian

Gangguan ringan
Gangguan bermakna

Diagnosis keperawatan
Perubahan proses pikir

Jelaskan : .....................................................................
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13. Daya Tilik Diri
Diagnosis keperawatan
Mengingkari penyakit yang diderita
Menyalahkan hal-hal di luar dirinya

Penatalaksanaan regimen
terapeutik individu inefektif
Ketidakpatuhan
Gangguan proses pikir

Jelaskan : .......................................................................
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G. KEBUTUHAN PERENCANAAN PULANG
1. Kemampuan klien memenuhi kebutuhan

Diagnosis keperawatan
Makanan
Perubahan pemeliharaan
Keamanan
kesehatan
Perawatan Kesehatan
Perilaku mencari bantuan
Pakaian
Transportasi
kesehatan tentang ..
Sindroma deficit
Tempat tinggal
perawatan diri
Uang
Jelaskan : ..................................................................................................

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2. Kegiatan hidup sehari-hari

a. Perawatan diri

Diagnosis keperawatan
Perubahan pemeliharaan kesehatan
Perilaku mencari bantuan kesehatan

Mandi
tentang ..
Kebersihan
Makan
Sindroma defisit perawatan diri: (Mandi,
BAK / BAB
makan, berhias berpakaian, toileting Ganti pakaian
Jelaskan : ................................................................................................
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b. Nutrisi
Apakah anda puas dengan pola makanDiagnosis
anda?
keperawatan
Ya
Tidak
Frekuensi makan sehari : .......... kali
Frekuensi kedapan sehari : ....... kali

Nafsu makan :

Ketidakseimbangan nutrisi:
kurang dari kebutuhan tubuh
Ketidakseimbangan nutrisi:
kurang dari kebutuhan tubuh
Perubahannutrisi potensial lebih
dari kebutuhan tubuh
Sindroma defisit perawatan diri:
(Mandi, makan, berhias
berpakaian, toileting - eliminasi)

Meningkat
Menurun
Berlebihan
Sedikit sedikit
Berat badan :
Meningkat
Menurun
BB terendah : ..........Kg

BB tertinggi : .......... Kg

Jelaskan : ................................................................................................
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c. Tidur
Apakah ada masalah tidur ?

YA / TIDAK

Apakah merasa segar setelah bangun tidur?

YA / TIDAK

Apakah ada kebiasaan tidur siang?

YA / TIDAK

Lama tidur siang : ........ Jam

Apa yang menolong
tidur ? ........................................................................
Tidur malam jam : ................................, berapa
jam : ...............................
Apakah ada gangguan tidur ?
Sulit untuk tidur
Bangun terlalu pagi
Somnambulisme
Terbangun saat tidur
Gelisah saat tidur
Berbicara saat tidur

Diagnosis keperawatan
Gangguan pola tidur
Kehilangan tidur

Jelaskan : .................................................................
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3. Penggunaan Obat
Bantuan minimal

Bantuan total

Diagnosis keperawatan
Penatalaksanaan regimen terapeutik individu inefektif
Penatalaksanaan Regimen terapeutik keluarga inefektif
Ketidakpatuhan
Konflik pengambilan keputusan

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4. Pemeliharaan Kesehatan
Ya

Tidak

Perawatan lanjutan
Sistem pendukung
Diagnosis keperawatan
Perilaku mencari bantuan tentang
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5. Aktivitas Di Dalam Rumah
Ya
Mempersiapkan
makanan
Menjaga kerapian
rumah
Mencuci pakaian
Diagnosis keperawatan
Sindroma defisit perawatan diri: (Mandi, makan,
berhias berpakaian, toileting - eliminasi)

Tidak

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6. Aktivitas Di Luar Rumah
Ya

Tidak

Belanja
Transportasi
Lain-lain

Diagnosis keperawatan
Perilaku mencari bantuan tentang
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Jelaskan: ............................................................................................................
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H. MEKANISME KOPING
Adaptif:
Bicara dengan orang lain
Mampu menyelesaikan
masalah
Teknik relokasi
Aktivitas konstruktif
Olah raga
Lainnya: ..................................
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Maladaptif:
Minum alkohol
Reaksi lambat/berlebih
Berkerja berlebihan
Menghindar
Menciderai diri
Lainnya: .............................
Diagnosis
keperawatan
Koping individu

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I.

MASALAH PSIKOSOSIAL DAN LINGKUNGAN

Masalah dengan dukungan kelompok/keluarga,
uraikan ..........................................................................................
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Masalah berhubungan dengan lingkungan,
uraikan .........................
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Masalah berhubungan dengan pendidikan,
uraikan .........................
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Masalah berhubungan dengan pekerjaan,
uraikan ...........................
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Masalah berhubungan dengan perumahan,
uraikan ........................
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Masalah berhubungan dengan ekonomi,
uraikan ............................
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Masalah berhubungan dengan pelayanan kesehatan,
uraikan .........
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Masalah berhubungan dengan lainnya,
uraikan ...............................
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Diagnosis keperawatan
Perubahan pemeliharaan kesehatan
Perilaku mencari bantuan kesehatan tentang

Ketidakberdayaan

J.

ASPEK MEDIS
Diagnosis
medis : ...............................................................................................

Terapi
medis

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K. DAFTAR DIAGNOSIS KEPERAWATAN
1. ......................................................................................................................
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2. ......................................................................................................................
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3. ......................................................................................................................
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4.

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5. ......................................................................................................................
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6. ......................................................................................................................
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7. ......................................................................................................................
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8. ......................................................................................................................
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9. ......................................................................................................................
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L.

CLINICAL PATHWAY

M.

DIAGNOSA KEPERAWATAN
1.
2.
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Lawang,
2012

Juni

Pengkaji

Yense Eldiana Dhita, S.

Kep.