LAPORAN

RESUME
ASUHAN
A. PENGKAJIAN KEPERAWATAN JIWA

1. IDENTITAS PASIEN
a. Nama Pasien : ............................................, Umur : .............th,( L ) / ( P )
b. Register :........................................,Tangga : ................................
c. Agama : .............................................................................................
d. Status : ( Menikah ) / ( Tidak menikah ) , Pendidikan : ...............
e. Pekerjaan : ............................................................................................
f. Alamat : ............................................................................................
...............................................................................................

2. KELUHAN UTAMA / ALASAN MASUK

……………………………………………………………..………………………………
…………………………………………………………..…………………………………
……………………………………………………………………………………………..
.........................................................……..……….......................................................……

3. RIWAYAT PENYAKIT SEKARANG ( KRONOLOGIS )

………………………………………………..……………………………………………
………………………………………………..……………………………………………
………………………………………………..……………………………………………
……………………………………………..………………………………………………
……..……................................................................................................................………
…………………………………………………………..…………………………………
……………………………………………………………..………………………………
………………………………………………………………………………………..........
.....................................................................................................…………..……...………
……………………................………………………………..............…………………....
..............................................................................................................................................
..............................................................................................................................................
..........................................................................................................................................…
..............................................................................................................................................
..........................................................................................................................................…
..............................................................................................................................................
..........................................................................................................................................…

B. STATUS MENTAL
1. KEADAAN UMUM
…………………………..…………………………………………………………………
…………………………..…………………………………………………………………
……………………………………………………………………………………………..
................................................................................................................……..……………
................................................................................................................……..……………
................................................................................................................……..……………
................................................................................................................……..……………

Doc . RESUME/ IGD RSJM / S1 – KEPERAWATAN & D III

01 / PJMK JIWA
 LAPORAN
RESUME
ASUHAN
2. PENAMPILAN KEPERAWATAN JIWA
……………………..………………………………………………………………………
……………………………………………………………………………..........................
.................................…………..………......................................................................……
…………………………………………………......………………………………………

Doc . RESUME/ IGD RSJM / S1 – KEPERAWATAN & D III

01 / PJMK JIWA
 LAPORAN
RESUME
ASUHAN
3. KESADARAN KEPERAWATAN JIWA
…………………………………………………......………………………………………
…………………………………………………......………………………………………
…………………………………………………......………………………………………
…………………………………………………......………………………………………
…………………………………………………......………………………………………

4. PEMBICARAAN
…………………………………………………......………………………………………
…………………………………………………......………………………………………
…………………………………………………......………………………………………
…………………………………………………......………………………………………

C. KEADAAN AFEK
…………………………………………………......………………………………………
…………………………………………………......………………………………………
…………………………………………………......………………………………………
…………………………………………………......………………………………………
…………………………………………………......………………………………………
…………………………………………………......………………………………………

D. PROSES BERPIKIR
…………………………………………………...........………………………………………
…………………………………………………...........………………………………………
…………………………………………………...........………………………………………
…………………………………………………...........………………………………………
…………………………………………………...........………………………………………

E. PERSEPSI
…………………………………………………...........………………………………………
…………………………………………………...........………………………………………
…………………………………………………...........………………………………………
…………………………………………………...........………………………………………
…………………………………………………...........………………………………………

F. DIAGNOSA KEPERAWATAN
………………………………….......................................................…………………...……
……………………………………,,,,…………………………………………………..……
………………………………………,,,,………………………………………………..……

G. RENCANA KEPERAWATAN
1. TUJUAN UMUM
………………………………………………..……………………………………………
………………………………………………..……………………………………………
……………………………………………..………………………………………………
……..……................................................................................................................………
…………………………………………………………..…………………………………
……………………………………………………………..………………………………
………………………………………………………………………………………..........
.....................................................................................................…………..……...………
 LAPORAN
RESUME
ASUHAN
KEPERAWATAN JIWA
Doc . RESUME/ IGD RSJM / S1 – KEPERAWATAN & D III
/ PJMK JIWA
02
 LAPORAN
RESUME
ASUHAN
2. TUJUAN KHUSUS KEPERAWATAN JIWA
………………………………………………..…………………………………………
…………………………………………………..………………………………………
…………………………………………………..………………………………………
……………..……............................................................................................................
…………………………………………………………..………………………………
………………………………………………………………..…………………………
…………………………………………………………………………………………….
..............................................................................................................…………..……...

D. TINDAKAN KEPERAWATAN
………………………………………………..………………………………………………
……………………………………………..…………………………………………………
………………………………………..……………………………………………………..
…………………………………………………………..……………………………………
……………………….....…………………………………..………………………………
……………………….....…………………………………..………………………………
……………………….....…………………………………..………………………………
……………………….....…………………………………..………………………………
……………………….....…………………………………..………………………………
……………………….....…………………………………..………………………………
……………………….....…………………………………..………………………………
……………………….....…………………………………..………………………………
……………………….....…………………………………..………………………………
……………………….....…………………………………..………………………………
……………………….....…………………………………..………………………………

E. TERAPI
………………………………………………..………………………………………………
……………………………………………..…………………………………………………
………………………………………..……………………………………………………..
……................................................................................................................……..................

F. EVALUASI
………………………………………………..………………………………………………
……………………………………………..…………………………………………………
………………………………………..……………………………………………………..…
…...................................................................................................................................………

Surabaya, ................. Mengetahui

Mahasiswa Kepala Ruangan Instalasi Gawat Darurat
Rumah Sakit Jiwa Menur Surabaya

Doc . RESUME/ IGD RSJM / S1 – KEPERAWATAN & D III

03 / PJMK JIWA
 LAPORAN
RESUME
ASUHAN
KEPERAWATAN JIWA
Arif Soeprijono, Skep. Ns
Nim : Nip : 19710722 199603 1 0033

Doc . RESUME/ IGD RSJM / S1 – KEPERAWATAN & D III

03 / PJMK JIWA
 LAPORAN
RESUME
ASUHAN
KEPERAWATAN JIWA

Doc . RESUME/ IGD RSJM / S1 – KEPERAWATAN & D III

/ PJMK JIWA