RESUME KEPERAWATAN JIWA

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OLEH :
NAMA
NIM

:
:

FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH MALANG

FORMAT PENGKAJIAN PROSES KEPERAWATAN JIWA

DI UNIT RAWAT JALAN
(POLIKLINIK KESEHATAN JIWA DAN INSTALASI GAWAT DARURAT)
I.

Data Demograf
Initial Pasien
: .......................................................
Usia
: ......................................
Jenis Kelamin
: .......................................................
Agama
: ......................................
Pendidikan
: .......................................................
No.
RM
: ......................................
Tanggal MRS
: .......................................................
Penanggungjawab : .......................................................
Alamat
: .......................................................
.......................................................

II.

Status Mental
A. PENGKAJIAN PADA PASIEN
a) Alasan MRS :
................................................................................................................
................................................................................................................
...................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
.............................
................................................................................................................
...................................
b) Stressor
:
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
.........................................................................
c) Respon terhadap stressor
:
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
...............................

d) Faktor predisposisi
:
1. Herediter :
.............................................................................................................
.............................................................................................................
................................................................................
2. Pola asuh:
.............................................................................................................
.............................................................................................................
................................................................................
.............................................................................................................
...........................................
3. Pengalaman traumatis
:
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
.....................................
e) Evaluasi dan validasi
:
1. Kemampuan ADL
:
.............................................................................................................
.............................................................................................................
...........................................................................................
2. Kemampuan bersosialisasi :
.............................................................................................................
.............................................................................................................
............................................................................................
3. Penanganan masalah :
.............................................................................................................
.............................................................................................................
...................................................................................
4. Kepatuhan terhadap minum obat :
.............................................................................................................
.............................................................................................................
.........................................................................................
5. Hambatan yang dihadapi pasien
.............................................................................................................
.............................................................................................................
...............................................................................................
B. PENGKAJIAN PADA KELUARGA
a) Persepsi terhadap masalah
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
..............................

................................................................................................................
.................................
b) Koping keluarga terhadap masalah
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
.........................
................................................................................................................
...................................
c) Kemampuan merawat penderita
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
.......................
................................................................................................................
.....................................
d) Kemampuan memanfaatkan sumber pelayanan kesehatan
................................................................................................................
................................................................................................................
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C. ANALISA DATA
No

DATA

DIAGNOSA
KEPERAWATAN

D. DAFTAR DIAGNOSA KEPERAWATAN

1. ................................................................................................................
...................................................
2. ................................................................................................................
.............................................
3. ................................................................................................................
.................................
4. ................................................................................................................
................................
5. ................................................................................................................
................................
E. PRIORITAS DIAGNOSA KEPERAWATAN
1. ................................................................................................................
..................................
2. ................................................................................................................
..................................
3. ................................................................................................................
..................................

Malang, ................................
.................
Perawat yang mengkaji,

_____________________________

NIM :

IMPLEMENTASI DAN EVALUASI

Nama pasien
: ....................................................
RM : ...................................
No

Diagnosa
Keperawatan

Tangg
al &
Jam

Ruangan

Implementasi

: ...................................................................
Tangg
al &
Jam

Evaluasi

No.