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 sesudah
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C. Therapi
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D. 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 : …………………………………………………

E. Status Mental
1. Persepsi sensori : …………………………………………………
2. Proses berpikir : …………………………………………………
3. Isi Pikir : …………………………………………………
4. Alam perasaan : …………………………………………………
5. Afek : …………………………………………………
6. Tingkat kesadaran : …………………………………………………
7. Daya tarik diri : …………………………………………………

F. Psikomotorik
1. Aktivitas : …………………………………………………
2. Pembicaraan : …………………………………………………
3. Interaksi wawancara : …………………………………………………
4. Penampilan : …………………………………………………
5. Pola Nutrisi : …………………………………………………
6. Pola Tidur : …………………………………………………
G. Analisa Data
Data
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Masalah Keperawatan
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H. Diagnosa Keperawatan
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I. Rencana dan Intervensi Keperawatan
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J. Implementasi dan Evaluasi
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