RESUME ASUHAN KEPERAWATAN DASAR PROFESI

DENGAN ............................................... PADA ...........

DI .......................................................................
Tanggal :......................................................

OLEH

NI MADE SRI EPA JAYANTI

NIM: 2114901078

PROGRAM STUDI PENDIDIKAN PROFESI KEPERAWATAN

INSTITUT TEKNOLOGI DAN KESEHATAN BALI
TAHUN 2021/2022
 RESUME ASUHAN KEPERAWATAN DASAR PROFESI
DENGAN ............................................... PADA ...........
DI .......................................................................

I. PENGKAJIAN
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A. Identitas Pasien

Ruang Rawat : Tanggal Masuk :

Initial : No R.M :
Umur : Status :
Pekerjaan : Pendidikan :
Jenis Kelamin :

B. Riwayat Kesehatan
1. Keluhan utama saat masuk RS.
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2. Keluhan utama saat pengkajian
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3. Riwayat penyakit sekarang
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C. Faktor predisposisi

1. Pernah mengalami ganngguan jiwa di masa lalu?

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2. Pengobatan sebelumnya
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3. Penolakan dari lingkungan
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4. Adakah anggota keluarga yang mengalami gangguan jiwa?
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5. Pengalaman masalalu yang tidak menyenangkan
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D. Faktor presipitasi
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E. Pemeriksaan fisik

1. Tanda vital
2. Ukuran
3. Keluhan fisik

F. Psikososial

1. Genogram
 2. Konsep diri
a. Harga diri
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3. Hubungan sosial
a. Spiritual
1) Kegiatan ibadah
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G. Status mental

1. Pembicaraan
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H. Mekanisme koping

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I. Masalah psikososial
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 J. Aspek Medis
Diagnosa medis :........................................................................................................
Terapi :

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K. Analisa data

No Data Subyektif Data Obyektif Kesimpulan

No Data Subyektif Data Obyektif Kesimpulan
 L. Rumusan masalah
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II. Diagnosa Keperawatan
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III. Perencanaan
A. Prioritas Diagnosa
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B. Rencana Keperawatan
 PELAKSANAAN DAN EVALUASI KEPERAWATAN KLIEN......
DENGAN ................................................................
DIRUANG...........................RSJ PROFINSI BALI
TANGGAL.............................................

Tindakan Keperawatan Evaluasi

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Diagnosa : .................................................................................................... .....
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Tindakan Keperawatan Evaluasi

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RENCANA TINDAK LANJUT

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Tindakan Keperawatan Evaluasi

Tanggal/Hari :...............................................................................................
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Data ......
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O: ...........................................................................................................................
Diagnosa : .................................................................................................... .......
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Tindakan .....
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RENCANA TINDAK LANJUT .....
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Tindakan Keperawatan Evaluasi

Tanggal/Hari :...............................................................................................
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Diagnosa : .................................................................................................... .......
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Tindakan .....
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RENCANA TINDAK LANJUT .............................................................................................................................
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Tindakan Keperawatan Evaluasi

Tanggal/Hari :...............................................................................................
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Diagnosa : .................................................................................................... O: ...........................................................................................................................
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Tindakan .............................................................................................................................
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RENCANA TINDAK LANJUT .....
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....................................................................................................................... TANDA TANGAN DAN NAMA TERANG
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Tindakan Keperawatan Evaluasi

Tanggal/Hari :...............................................................................................
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Data
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O: ...........................................................................................................................
Diagnosa : .................................................................................................... .......
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Tindakan .....
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RENCANA TINDAK LANJUT .............................................................................................................................
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