RESUME KEPERAWATAN JIWA PADA KLIEN AN.G.

M DENGAN
SKIZOFRENIA DI RUANGAN KESWARA RS JIWA CISARUA
KABUPATEN BANDUNG 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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Masalah Keperawatan : .......................................................................................................
4. Riwayat penyakit keluarga yang mengalami gangguan jiwa
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Masalah Keperawatan : .......................................................................................................
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

Penjelasan:
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2. Konsep Diri
a. Gambaran diri
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b. Identitas
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c. Peran
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 d. Ideal diri
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e. Harga diri
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Masalah Keperawatan : .......................................................................................................
3. Hubungan Sosial
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Masalah Keperawatan : .......................................................................................................
4. Spiritual
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Masalah Keperawatan : .......................................................................................................

VI. Status Mental

1. Penampilan
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Masalah Keperawatan : .......................................................................................................
2. Pembicaraan
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Masalah Keperawatan : .......................................................................................................
3. Aktivitas motorik
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4. Alam perasaan
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5. Afek
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Masalah Keperawatan : .......................................................................................................
6. Interaksi selama wawancara
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Masalah Keperawatan : .......................................................................................................
7. Persepsi
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Masalah Keperawatan : .......................................................................................................
8. Proses pikir
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Masalah Keperawatan : .......................................................................................................
9. Isi pikir
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10. Waham
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Masalah Keperawatan : .......................................................................................................
11. Tingkat kesadaran
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12. Memori
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13. Kemampuan penilaian
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14. Daya tilik diri
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VII. Kebutuhan Persiapan Pulang

1. Makan
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2. BAB/BAK
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3. Mandi
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4. Berpakaian/berhias
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5. Istirahat dan tidur
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6. Penggunaan obat
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7. Pemeliharaan kesehatan
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8. Kegiatan didalam rumah
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9. Aktivitas didalam rumah
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VIII. Mekanisme Koping
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Masalah Keperawatan : .......................................................................................................

IX. Masalah Psikososial Dan Lingkungan

1. Masalah dukungan kelompok
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2. Masalah yang berhubungan dengan lingkungan
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3. Masalah dengan pendidikan
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4. Masalah dengan pekerjaan
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5. Masalah ekonomi
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6. Masalah dengan pelayanan kesehatan
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 7. Masalah lainnya
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X. Pengetahuan Kurang Tentang
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Bandung, April 2019

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 ANALISA DATA

No. Data Masalah Keperawatan

Diagnosa Keperawatan Prioritas:
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6. ……………………………………………………………………………………………
7. ……………………………………………………………………………………………
 RENCANA KEPERAWATAN
No Dx Diagnosa Tujuan Kriteria Evaluasi Intervensi Rasional
Kep 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