RESUME KEPERAWATAN JIWA PADA DENGAN

DI RUANGAN KESWARA
RSJ PROVINSI JAWA BARAT

I. Identitas Klien
Inisial : (L/P) Tanggal Pengkajian :
Umur : Rm No. :
Informan :

Identitas Penangggungjawab
Inisial :
Umur :
Hubungan :

II. Alasan Masuk

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III. Faktor Predisposisi

1. Pernah mengalami gangguan jiwa di masa lalu
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 2. Pengobatan sebelumnya
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3. Riwayat Perilaku Kekerasan
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4. Riwayat penyakit keluarga yang mengalami gangguan jiwa

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5. Pengalaman masa lalu yang tidak menyenangkan
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IV. Fisik
TD : ................. N: ................... SB : .................... R: .......................
TB: .................. BB: ...................
Keluhan fisik :
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V. Psikososial
1. Genogram

VI. Therapi Obat

 ANALISA DATA
No. Data Masalah Keperawatan
 RENCANA KEPERAWATAN
No Dx Diagnosa Tujuan Kriteria Evaluasi Intervensi Rasional
Kep Keperawatan
 IMPLEMENTASI DAN EVALUASI
Inisial pasien : Ruangan :
No. RM :
Dx.
Hari/Tgl Jam Implementasi Evaluasi
Kep
Dx.
Hari/Tgl Jam Implementasi Evaluasi
Kep
Nama Obat Manfaat Efek Samping