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LAPORAN RESUME KEPERAWATAN JIWA

PROGRAM STUDI ILMU KEPERAWATAN


FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

A. PENGKAJIAN

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

2. KELUHAN UTAMA / ALASAN MASUK


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3. RIWAYAT PENYAKIT SEKARANG


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B. STATUS MENTAL
1. KEADAAN UMUM
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2. PENAMPILAN
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3. KESADARAN
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LAPORAN RESUME KEPERAWATAN JIWA
PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

4. PEMBICARAAN
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C. KEADAAN AFEK
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D. PROSES PIKIR
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E. PERSEPSI
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F. DIAGNOSA KEPERAWATAN
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G. RENCANA KEPERAWATAN
1. TUJUAN UMUM
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LAPORAN RESUME KEPERAWATAN JIWA
PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

2. TUJUAN KHUSUS
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D. TINDAKAN KEPERAWATAN
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E. TERAPI
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F. EVALUASI
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LAPORAN RESUME KEPERAWATAN JIWA
PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA