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ASUHAN KEPERAWATAN

KEGAWAT DARURATAN PSIKIATRI

A. Identitas
 Nama klien : ...............................................................
 Jenis kelamin : ...............................................................
 Umur : ...............................................................
 Alamat : ...............................................................
 No RM : ...............................................................
 Tanggal Masuk : ...............................................................
 Nama Penanggung Jawab : ...............................................................
 Alamat Penanggung Jawab : ...............................................................
 Hubungan dengan klien : ...............................................................

B. Riwayat Penyakit
1. Alasan Masuk
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2. Riwayat Penyakit
Riwayat penyakit sebelum
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Riwayat penyakit sekarang
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C. Diagnosis Medis
 Axis I :…………………………………..
 Axis II :………………………………….
 Axis III :………………………………….
 Axis IV :………………………………….
 Axis V :………………………………….

D. Therapi
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E. Tahap Penanganan
1. Tahap Penanganan : ………………………………………………….......................
2. Skor : ………………………………………………….......................
3. Tujuan Penanganan : ………………………………………………….......................
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4. Prinsip Penanganan …………………………………………………........................
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5. Hal yang dievaluasi : …………………………………………………......................

F. Status Mental
1. Persepsi sensori : …………………………………………………........................
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2. Proses berpikir : …………………………………………………........................
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3. Isi Pikir : …………………………………………………........................
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4. Alam perasaan : …………………………………………………........................
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5. Afek : …………………………………………………........................
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6. Tingkat kesadaran : …………………………………………………........................
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7. Daya tarik diri : …………………………………………………........................
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G. Psikomotorik
1. Aktivitas : …………………………………………………........................
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2. Pembicaraan : …………………………………………………........................
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3. Interaksi wawancara : …………………………………………………........................
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4. Penampilan : …………………………………………………........................
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5. Pola Nutrisi : …………………………………………………........................
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6. Pola Tidur : …………………………………………………........................
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H. Analisa Data
Data Masalah Keperawatan
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I. Diagnosa Keperawatan
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