ASUHAN KEPERAWATAN JIWA PADA PASIEN : .............

DENGAN : ..................................................................................................................

I. TINJAUAN KASUS
A. PENGKAJIAN
a) Nama : .......................................................................................
b) Penanggung jawab : .......................................................................................
c) Alasan masuk : ........................................................................................
d) No RM : ........................................................................................
e) Diagnosis medis : .......................................................................................
f) Faktor predisposisi : .......................................................................................
g) Psikososial : ........................................................................................
h) Konsep diri : ........................................................................................
1. Gambaran diri
..............................................................................................................
2. Identitas diri
..............................................................................................................
3. Peran diri
.............................................................................................................
4. Harga diri
.............................................................................................................
i) Status mental
1. Penampilan
..............................................................................................................
2. Komunikasi
..............................................................................................................
3. Aktivitas motorik
..............................................................................................................
4. Alam perasaan
..............................................................................................................
5. Afek
..............................................................................................................
6. Interaksi ketika wawancara
..............................................................................................................
7. Memori
..............................................................................................................
8. Persepsi
..............................................................................................................
9. Proses pikir
..............................................................................................................
10. Isi pikir
..............................................................................................................
B. ANALISA DATA

Hari/tgl/Jam No Diagnosa Data focus Masalah Paraf

keperawatan
...................... ................... DS ..................... .................
:.................

DO :..................
..

C. POHON MASALAH

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
..............................................................................................................................................

D. DIAGNOSA KEPERAWATAN :

1. ...........................................................................................................................................

2. ..........................................................................................................................................

3. ..........................................................................................................................................

4. ..........................................................................................................................................
 F. RENCANA KEPERAWATAN

DX KEPERAWATAN RENCANA TINDAKAN RASIONAL

TUJUAN KRITERIA EVALUASI TINDAKAN KEPERAWATAN

1. .......................... TUM : PSIKOTERAPI ...........................................

........................................ ........................................
2. .......................... ...........................................

3. ............................ ...........................................

PSIKOFARMAKA
...........................................

TUK:
.......................................

TINDAKAN MANIPULASI
LINGKUNGAN
...........................................

KET :

G. CATATAN KEPERAWATAN
HARI/TGL/ JAM No DX / SP IMPLEMENTASI EVALUASI PARAF

PSIKOTERAPI S :...............................................................
........................................

O :..............................................................

A :................................................................

PSIKOFARMAKA P :................................................................
...........................................

TINDAKAN MANIPULASI LINGKUNGAN

...........................................