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  • Format Resume Ipcu

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    Sulendra Gede
    14 tayangan11 halaman
    Resume asuhan keperawatan pasien dengan gangguan jiwa yang dirawat di rumah sakit. Terdapat pengkajian identitas pasien, riwayat kesehatan seperti keluhan utama, riwayat penyakit saat ini, faktor predisposisi seperti riwayat gangguan jiwa masa lalu, dan pengobatan sebelumnya. Juga terdapat faktor presipitasi yang memicu gangguan jiwa pasien.

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    Resume asuhan keperawatan pasien dengan gangguan jiwa yang dirawat di rumah sakit. Terdapat pengkajian identitas pasien, riwayat kesehatan seperti keluhan utama, riwayat penyakit saat ini, faktor predisposisi seperti riwayat gangguan jiwa masa lalu, dan pengobatan sebelumnya. Juga terdapat faktor presipitasi yang memicu gangguan jiwa pasien.

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    © All Rights Reserved
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    14 tayangan11 halaman

    Format Resume Ipcu

    Diunggah oleh

    Sulendra Gede
    Resume asuhan keperawatan pasien dengan gangguan jiwa yang dirawat di rumah sakit. Terdapat pengkajian identitas pasien, riwayat kesehatan seperti keluhan utama, riwayat penyakit saat ini, faktor predisposisi seperti riwayat gangguan jiwa masa lalu, dan pengobatan sebelumnya. Juga terdapat faktor presipitasi yang memicu gangguan jiwa pasien.

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    dari 11

    RESUME ASUHAN KEPERAWATAN

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


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

    OLEH

    NI PUTU DENTIKA ASVINI


    NIM: 2114901188

    FAKULTAS KESEHATAN
    PROGRAM STUDI PENDIDIKAN PROFESI KEPERAWATAN
    INSTITUT TEKNOLOGI DAN KESEHATAN BALI
    2022
    RESUME ASUHAN KEPERAWATAN
    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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    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
    1. ...................................................................................................................................
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    2. ...................................................................................................................................
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    II. Diagnosa Keperawatan
    A. ..........................................................................................................................................
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    III. Perencanaan
    A. Prioritas Diagnosa
    ..........................................................................................................................................
    ..........................................................................................................................................
    B. Rencana Keperawatan
    Tindakan Keperawatan Evaluasi

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

    Tanggal/Hari :..........................................................................................................
    Data S: ..................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    O: ..................................................................................................................................
    Diagnosa : ............................................................................................................... ..................................................................................................................................
    Tindakan ..................................................................................................................................
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    .................................................................................................................................. ..................................................................................................................................
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    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. A: ................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    RENCANA TINDAK LANJUT P: .................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. ..................................................................................................................................
    .................................................................................................................................. TANDA TANGAN DAN NAMA TERANG
    ..................................................................................................................................
    ..................................................................................................................................
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