FORMAT PENGKAJIAN

KEPERAWATAN KESEHATAN JIWA

Ruang rawat : EDELWEIS Tanggal dirawat : 8 Maret 2023

A. IDENTITAS KLIEN
Nama : Ny. A No. CM : 153568
Jenis Kelamin : Perempuan Umur : tahun
Tanggal masuk : 8 Maret 23 Pendidikan : SD
Agama : Islam Suku : Jawa
Status Perkawinan : Kawin Pekerjaan : Tidak bekerja
Tanggal Pengkajian : 8 Maret 23
B. ALASAN MASUK/FAKTOR PRESIPITASI
Pasien mengeluh lemas ,Mual (+), Muntah (+), sering setiap kali makan dan minum
C. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu?

YA
TIDAK Diagnosis keperawatan
Pasien mengatakan tidak pernah  Perubahan pertumbuhan dan
2. Pengobatan sebelumnya? perkembangan
 Berduka antisipasi
Berhasil  Berduka disfungsional
 Respon pasca trauma
Kurang berhasil  Sindroma trauma perkosaan
Tidak berhasil  Perilaku kekkerasan
 Risiko perilaku kekerasan: (pada diri,
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orang lain, lingkungan, verbal)
................................................................  ……………………………………………..
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3. Trauma

Usia Pelaku Korban Saksi

Aniaya fisik ........... ........... ........... ...........
Aniaya seksual ........... ........... ........... ...........
Penolakan ........... ........... ........... ...........
Kekerasan dalam keluarga ........... ........... ........... ...........
Tindakan kriminal ........... ........... ........... ...........
Jelaskan : .................................................................................................................
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4. Anggota keluarga yang gangguan jiwa Diagnosis keperawatan
YA  Koping keluarga tidak efektif :
TIDAK ketidakmampuan
Jika ada :  Koping keluarga tidak efektif: kompromi
 Risiko perilaku kekerasan: (pada diri,
Hubungan keluarga : ................................................................................................
orang lain, lingkungan, verbal)
Gejala : .................................................................................................
 ……………………………………………..
Riwayat pengobatan : .................................
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5. Pengalaman masa lalu yang tidak menyenangkan Diagnosis keperawatan

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

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D. PEMERIKSAAN FISIK
1. Tanda Vital :
Sebelum masuk RS : TD .....................mmHg HR : .........kali / menit
S .................... oC RR : ......... kali / menit
Masuk RS : TD .....................mmHg HR : .........kali / menit
S .................... oC RR : ......... kali / menit
2. Ukur :
Sebelum masuk RS : BB .......................... Kg TB : ......... cm
masuk RS : BB .......................... Kg TB : ......... cm
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3. Keluhan fisik
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Diagnosis keperawatan  Perubahannutrisi potensial lebih dari

 Risiko tinggi perubahan suhu tubuh kebutuhan tubuh
 Defisit volume cairan  Kerusakan integritas jaringan
 Risiko tinggi terhadap infeksil  Perubahan membran mukosa oral
 Ketidakseimbangan nutrisi: kurang dari  Kerusakan integritas kulit
kebutuhan tubuh  Perubahan eliminasi feses
 Ketidakseimbangan nutrisi: kurang dari  Perubahan pola eliminasi urin
kebutuhan tubuh  ……………………………………………..

E. PSIKOSOSIAL
1. Genogram

Diagnosis keperawatan
 Koping keluarga tidak efektif:
ketidakmampuan
 Koping keluarg tidak efektif: kompromi
 ……………………………………………..
Jelaskan : ....................................................................................................................................
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Konsep Diri:
a. Citra Tubuh : .....................................................................................................................
Diagnosis keperawatan
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 Gangguan citra tubuh
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 Gangguan identitas pribadi
b. Identitas : ....................................................................................................................
 Harga diri rendah kronis
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 Harga diri rendah situasional
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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
a. Orang yang berarti : ................................ Diagnosis keperawatan
...................................................................  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
a. Nilai dan keyakinan ................................................ Diagnosis keperawatan
................................................................................  Distres spiritual
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b. Kegiatan ibadah ..................................................................................................................
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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

Penggunaan pakaian tidak sesuai Diagnosis keperawatan

Cara berpakaian tidak seperti biasanya  Defisit perawatan diri (berpakaian dan
berhias)
Jelaskan : ...............................................................
 ……………………………………………..
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2. Pembicaraan Diagnosis keperawatan

 Kerusakan komunikasi verbal
Cepat Apatis
 ……………………………………………..
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
Diagnosis keperawatan
Datar
 Risiko cidera
Tumpul  Kerusakan komunikasi verbal
Labil  Kerusakan interaksi sosial
Tidak sesuai  ……………………………………………..
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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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 ……………………………………………..
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6. Persepsi - Sensorik
Halusinasi/Ilusi? ADa / Tidak? Diagnosis keperawatan

Pendengaran  Gangguan persepsi sensori: Halusianasi

Penglihatan (pendengaran/penglihatan/pengecap/penghid
Perabaan u/peraba)
 ……………………………………………..
Pengecapan
Penghidu
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7. Isi pikir
Obesi Depersonalisasi Diagnosis keperawatan
Phobia Ide yang terkait Waham :
Hipokondria Pikiran magis  Perubahan proses pikir
Agama Nihilistik  Kerusakan komunikasi verbal
Somatik Sisip pikir  ……………………………………………..
Kebesaran Siar pikir
Curiga Kontrol pikir
Jelaskan : ....................................................................
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8. Proses pikir

Circumstansial Flight of idea

Tangensial Blocking
Kehilangan asosiasi Pengulangan pembicaraan / perseverasi
Jelaskan : ................................................................................................................................
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9. Tingkat Kesadaran
Diagnosis keperawatan

Bingung Disorientasi waktu  Risiko cidera

Sedasi Disorientasi orang  Gangguan proses pikir
Stupor Disorientasi tempat  ………………………………………
Disorientasi Lingkungan
Jelaskan
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10. Memori
Diagnosis keperawatan
Gangguan daya ingat jangka panjang  Perubahan proses pikir
Gangguan daya ingat jangka pendek  ………………………………………
Gangguan daya ingat saat ini
Konfabulasi
 Jelaskan : ............................................................................................................
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11. Tingkat konsentrasi dan berhitung

Diagnosis keperawatan
Mudah beralih  Perubahan proses pikir
 ………………………………………
Tidak mampu berkonsentrasi
Tidak mampu berhitung sederhana

Jelaskan : .........................................................................................................
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12. Kemampuan penilaian
Diagnosis keperawatan
 Perubahan proses pikir
Gangguan ringan  ………………………………………
Gangguan bermakna
Jelaskan : .....................................................................
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13. Daya Tilik Diri Diagnosis keperawatan
 Penatalaksanaan regimen terapeutik
individu inefektif
 Ketidakpatuhan
 Gangguan proses pikir
 ………………………………………
 Mengingkari penyakit yang diderita

Menyalahkan hal-hal di luar dirinya

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

Makanan
Keamanan
Perawatan Kesehatan Diagnosis keperawatan
Pakaian  Perubahan pemeliharaan
Transportasi kesehatan
Tempat tinggal  Perilaku mencari bantuan
Uang kesehatan tentang …..
 Sindroma deficit perawatan diri
Jelaskan : ..................................................................................................................
 ………………………………………
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Diagnosis keperawatan
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 Perubahan pemeliharaan kesehatan
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 Perilaku mencari bantuan kesehatan tentang …..
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 Sindroma defisit perawatan diri: (Mandi, makan,
berhias – berpakaian, toileting - eliminasi)
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 Perubahan elimanasi feses
 Perubahan pola eliminasi urin
2. Kegiatan hidup sehari-hari
a. Perawatan diri

Mandi
Kebersihan
Makan
BAK / BAB
Ganti pakaian
Jelaskan : ............................................................................................................................
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b. Nutrisi
Apakah anda puas dengan pola makan anda?
Diagnosis keperawatan
 Ketidakseimbangan nutrisi: kurang dari
Ya kebutuhan tubuh
Tidak  Ketidakseimbangan nutrisi: kurang dari
Frekuensi makan sehari : .......... kali kebutuhan tubuh
 Perubahannutrisi potensial lebih dari
Frekuensi kedapan sehari : ....... kali kebutuhan tubuh
Nafsu makan :  Sindroma defisit perawatan diri: (Mandi,
makan, berhias – berpakaian, toileting -
Meningkat eliminasi)
 ………………………………………
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 ? Diagnosis keperawatan

Sulit untuk tidur  Gangguan pola tidur

Bangun terlalu pagi  Kehilangan tidur
Somnambulisme
Terbangun saat tidur
 Gelisah saat tidur
Berbicara saat 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 Tidak
Mempersiapkan makanan
Menjaga kerapian rumah
Mencuci pakaian

Diagnosis keperawatan
 Sindroma defisit perawatan diri: (Mandi, makan, berhias –
berpakaian, toileting - eliminasi)
 ………………………………………
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6. Aktivitas Di Luar Rumah

Ya Tidak Diagnosis keperawatan

Belanja
Transportasi  Perilaku mencari bantuan tentang ….
Lain-lain  ………………………………………
Jelaskan: .......................................................................................................................
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H. MEKANISME KOPING

Adaptif: Maladaptif:
Bicara dengan orang lain Minum alkohol
Mampu menyelesaikan masalah Reaksi lambat/berlebih
Teknik relokasi Berkerja berlebihan
Aktivitas konstruktif Menghindar
Olah raga Menciderai diri
Lainnya: ......................................... Lainnya: .............................
Diagnosis keperawatan
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.................................................  Koping individu inefektif
.................................................  ………………………………………
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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
Diagnosis keperawatan dengan lainnya, uraikan ...............................
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 Perubahan pemeliharaan kesehatan
 Perilaku mencari bantuan kesehatan tentang ……………
 Ketidakberdayaan
 Konflik peran orang tua
 Sindroma stres Relokasi
 Penatalaksanaan regimen terapeutik individu inefektif
 Penatalaksanaan Regimen terapeutik keluarga inefektif

J. ASPEK MEDIS
Diagnosis medis : ...............................................................................................
Terapi medis : ...............................................................................................
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K. DAFTAR DIAGNOSIS KEPERAWATAN
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L. CLINICAL PATHWAY
M. DIAGNOSA KEPERAWATAN
1.
2.
3.

, 2022

Perawat