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FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

Ruang rawat : .......... Tanggal dirawat: .............

A. IDENTITAS KLIENNama : Status Perkawinan :Jenis Kelamin : Suku :Umur : No. CM :Alamat : Tanggal masuk :Agama : Tanggal Pengkajian :Pendidikan : Sumber Informasi :Pekerjaan :

B. ALASAN MASUK/FAKTOR PRESIPITASI.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

C. FAKTOR PREDISPOSISI1. Pernah mengalami gangguan jiwa di masa lalu?

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2. Pengobatan sebelumnya?

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Diagnosis keperawatan Perubahan pertumbuhan dan

perkembangan Berduka antisipasi Berduka disfungsional Respon pasca trauma Sindroma trauma perkosaan Perilaku kekkerasan Risiko perilaku kekerasan: (pada

diri, orang lain, lingkungan, verbal) ……………………………………………..

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3. Trauma

Usia Pelaku Korban SaksiAniaya fisik ........... ........... ........... ...........Aniaya seksual ........... ........... ........... ...........Penolakan ........... ........... ........... ...........Kekerasan dalam keluarga ........... ........... ........... ...........Tindakan kriminal ........... ........... ........... ...........

Jelaskan : ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Anggota keluarga yang gangguan jiwaYATIDAK

Jika ada :Hubungan keluarga : ................................................................................................Gejala : .................................................................................................Riwayat pengobatan : .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

5. Pengalaman masa lalu yang tidak menyenangkan

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Diagnosis keperawatan Koping keluarga tidak efektif :

ketidakmampuan Koping keluarga tidak efektif: kompromi Risiko perilaku kekerasan: (pada diri,

orang lain, lingkungan, verbal) ……………………………………………..

Diagnosis keperawatan Perubahan pertumbuhan dan

perkembangan Berduka antisipatif Berduka disfungsional Respon pasca trauma Sindroma trauma paska

perkosaan ……………………………………………..

D. PEMERIKSAAN FISIK1. Tanda Vital :

Saat masuk RS : TD .....................mmHg HR : .........kali / menitS .................... oC RR : ......... kali / menitSaat pengkajian : TD .....................mmHg HR : .........kali / menit S .................... oC RR : ......... kali / menit

2. Ukur : Saat masuk RS : BB .......................... Kg TB : ......... cmSaat pengkajian : BB .......................... Kg TB : ......... cm...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Keluhan fisik...........................................................................................................................................................................................................................................................................................................................................................................................................................................................

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 ……………………………………………..

E. PSIKOSOSIAL1. Genogram

Jelaskan : .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Diagnosis keperawatan Koping keluarga tidak efektif:

ketidakmampuan Koping keluarg tidak efektif: kompromi ……………………………………………..

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Konsep Diri:a. Citra Tubuh : .....................................................................................................................

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............................................................................................................................................b. Identitas : ....................................................................................................................

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...........................................................................................................................................c. Peran

: ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

d. Ideal Diri : ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

e. Harga Diri : .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2. Hubungan sosiala. Orang yang berarti : ................................

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Diagnosis keperawatan Gangguan citra tubuh Gangguan identitas pribadi Harga diri rendah kronis Harga diri rendah situasional ……………………………………………..

Diagnosis keperawatan Kerusakan komunikasi verbal Kerusakan Interaksi sosial Isolasi sosial ……………………………………………..

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.b. Peran serta dalam kegiatan kelompok

/ masyarakat ……………………………………................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

c. Hambatan dalam berhubungan dengan orang lain …………………………………………...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Spirituala. Nilai dan keyakinan ................................................

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.............................................................................................................................................b. Kegiatan ibadah ..................................................................................................................

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F. STATUS MENTAL1. 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

Cara berpakaian tidak seperti biasanya

Jelaskan : ...............................................................

Diagnosis keperawatan Distres spiritual ……………………………………………

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Diagnosis keperawatan

Defisit perawatan diri (berpakaian dan berhias)

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2. Pembicaraan

Cepat ApatisKeras LambatGagap MembisuInkoherensi Tidak mampu memulai pembicaraan

Jelaskan : ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Aktivitas motorik

Lesu TikTegang GrimasemGelisah TremorAgitasi Kompulsif

Jelaskan : ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Alam perasaan

Sedih

Ketakutan

Putus asa

Khawatir

Gembira berlebihan.................................................................................................................................................................................................................................................................

Diagnosis keperawatan Kerusakan komunikasi verbal ……………………………………………..

Diagnosis keperawatan Risiko cidera Perilaku kekerasan ……………………………………………..

Diagnosis keperawatan Risiko cidera Ansietas Ketakutan Keputusasaan Ketidakberdayaan Risiko bunuh diri Risiko tinggi membahayakan diri ……………………………………………..

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5. Afek

Datar

Tumpul

Labil

Tidak sesuai...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Interaksi selama wawancara

Bermusuhan

Tidak kooperatif

Mudah tersinggung

Kontak mata kurang

Curiga....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

6. Persepsi - Sensorik


Risiko cidera Kerusakan komunikasi verbal Kerusakan interaksi sosial ……………………………………………..

Diagnosis keperawatan Kerusakan komunikasi verbal Kerusakan interaksi sosial Isolasi sosial Risiko bunuh diri Risiko tinggi membahayakan diri Perilaku kekerasan Risiko perilaku kekerasan : (pada diri, orang lain,

lingkungan, verbal) ……………………………………………..

Halusinasi/Ilusi? ADa / Tidak?

Pendengaran

Penglihatan

Perabaan

Pengecapan

Penghidu.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

7. Isi pikir

Waham :

Agama Nihilistik Somatik Sisip pikirKebesaran Siar pikirCuriga Kontrol pikir

Jelaskan : ..................................................................................................................................................................................................................................................................................................................................

8. Proses pikir

Obesi DepersonalisasiPhobia Ide yang terkaitHipokondria Pikiran magis


Gangguan persepsi sensori: Halusianasi (pendengaran/penglihatan/pengecap/penghidu/peraba)

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Perubahan proses pikir Kerusakan komunikasi verbal ……………………………………………..

Circumstansial Flight of ideaTangensial Blocking Kehilangan asosiasi Pengulangan pembicaraan / perseverasi

Jelaskan : .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9. Tingkat Kesadaran

Bingung Disorientasi waktuSedasi Disorientasi orang

StuporDisorientasi LingkunganJelaskan

Disorientasi tempat

10. Memori

Gangguan daya ingat jangka panjangGangguan daya ingat jangka pendekGangguan daya ingat saat iniKonfabulasi

Jelaskan : .........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................


Risiko cidera Gangguan proses pikir ………………………………………

Diagnosis keperawatan Perubahan proses pikir ………………………………………

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11. Tingkat konsentrasi dan berhitung

Mudah beralih

Tidak mampu berkonsentrasi

Tidak mampu berhitung sederhana

Jelaskan : ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

12. Kemampuan penilaian

Gangguan ringan

Gangguan bermakna

Jelaskan : .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

13. Daya Tilik Diri

Mengingkari penyakit yang diderita


Diagnosis keperawatan Penatalaksanaan regimen terapeutik

individu inefektif Ketidakpatuhan Gangguan proses pikir ………………………………………


Menyalahkan hal-hal di luar dirinya

Jelaskan : .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

G. KEBUTUHAN PERENCANAAN PULANG

1. Kemampuan klien memenuhi kebutuhan

MakananKeamanan Perawatan KesehatanPakaianTransportasiTempat tinggal Uang

Jelaskan : ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2. Kegiatan hidup sehari-haria. Perawatan diri

MandiKebersihanMakanBAK / BAB

Diagnosis keperawatan Perubahan pemeliharaan

kesehatan Perilaku mencari bantuan

kesehatan tentang ….. Sindroma deficit perawatan diri ………………………………………


Perubahan pemeliharaan kesehatan Perilaku mencari bantuan kesehatan tentang ….. Sindroma defisit perawatan diri: (Mandi, makan,

berhias – berpakaian, toileting - eliminasi) Perubahan elimanasi feses Perubahan pola eliminasi urin

Ganti pakaianJelaskan : ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

b. NutrisiApakah anda puas dengan pola makan anda?

YaTidak

Frekuensi makan sehari : .......... kaliFrekuensi kedapan sehari : ....... kali

Nafsu makan :

MeningkatMenurunBerlebihanSedikit – sedikit

Berat badan :

MeningkatMenurun

BB terendah : ..........Kg BB tertinggi : .......... KgJelaskan : .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

c. TidurApakah ada masalah tidur ? YA / TIDAKApakah merasa segar setelah bangun tidur? YA / TIDAKApakah ada kebiasaan tidur siang? YA / TIDAK

Diagnosis keperawatan 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)

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Lama tidur siang : ........ JamApa yang menolong tidur ? ........................................................................Tidur malam jam : ................................, berapa jam : ...............................Apakah ada gangguan tidur ?

Sulit untuk tidur

Bangun terlalu pagiSomnambulismeTerbangun saat tidurGelisah saat tidurBerbicara saat tidur

Jelaskan : .................................................................................................................................................... ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Penggunaan Obat

Bantuan minimal Bantuan total

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...............................................................................................................................................4. Pemeliharaan Kesehatan

Ya TidakPerawatan lanjutanSistem pendukung

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Gangguan pola tidur Kehilangan tidur

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

Diagnosis keperawatan Perilaku mencari bantuan tentang …………………………………. ………………………………………

....................................................................................................................................................5. Aktivitas Di Dalam Rumah

Ya TidakMempersiapkan makananMenjaga kerapian rumahMencuci pakaian

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...................................................................................................................................................6. Aktivitas Di Luar Rumah

Ya TidakBelanjaTransportasiLain-lain

Jelaskan: ....................................................................................................................... ...............................................................................................................................................................................................................................................................................................................................................................................................................................

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..........................................................................................................................................................H. MEKANISME KOPING

Adaptif: Maladaptif:Bicara dengan orang lain Minum alkoholMampu menyelesaikan masalah Reaksi lambat/berlebihTeknik relokasi Berkerja berlebihanAktivitas konstruktif Menghindar Olah raga Menciderai diri

Diagnosis keperawatan Sindroma defisit perawatan diri: (Mandi, makan, berhias –

berpakaian, toileting - eliminasi) ………………………………………


Perilaku mencari bantuan tentang …. ………………………………………

Lainnya: .........................................

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Lainnya: .............................

I. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

Masalah dengan dukungan kelompok/keluarga, uraikan .........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan lingkungan, uraikan .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan pendidikan, uraikan ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan pekerjaan, uraikan ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan perumahan, uraikan ...........................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan ekonomi, uraikan ...............................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan pelayanan kesehatan, uraikan .........................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah berhubungan dengan lainnya, uraikan .......................................................................................................................................................................................................................................................


Koping individu inefektif ………………………………………


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 MEDISDiagnosis medis : ...............................................................................................Terapi medis : ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

K. DAFTAR DIAGNOSIS KEPERAWATAN1. .................................................................................................................................2. .................................................................................................................................3. .................................................................................................................................4. .................................................................................................................................5. .................................................................................................................................6. .................................................................................................................................7. .................................................................................................................................8. .................................................................................................................................9. .................................................................................................................................10. .................................................................................................................................11. .................................................................................................................................12. .................................................................................................................................13. .................................................................................................................................14. .................................................................................................................................15. .................................................................................................................................

L. CLINICAL PATHWAY

M. DIAGNOSA KEPERAWATAN 1. 2. 3.

Lawang, Juni 2012

Pengkaji

Yense Eldiana Dhita, S. Kep.

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