FORMAT ASUHAN KEPERAWATAN JIWA

FORMAT PENGKAJIAN PSIKOSOSIAL

A. IDENTITAS

Nama pasien : _______________________________________________

Umur :________________________________________________

Jenis kelamin :________________________________________________

Status Perkawinan :________________________________________________

Orang yang berarti :________________________________________________

Pekerjaan :________________________________________________

Pendidikan :________________________________________________

B. PERSEPSI DAN HARAPAN

1. Pasien:_____________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

2. Keluarga:___________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

C. STATUS MENTAL
CANDRA AGUS WIDODO/2231061014
Institut Teknologi Kesehatan Malang
Widya Cipta Husada 2022
 1. Emosi:______________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

__________________________________________________________________________

2. Konsep Diri :

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

3. Pola Interaksi :

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

4. Gaya Komunikasi :

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

D. LATAR BELAKANG STATUS SOSIAL BUDAYA

CANDRA AGUS WIDODO/2231061014

Institut Teknologi Kesehatan Malang
Widya Cipta Husada 2022
 1. Pekerjaan :

___________________________________________________________________________

___________________________________________________________________________

2. Hubungan Sosial :

___________________________________________________________________________

___________________________________________________________________________

3. Gaya Hidup :

___________________________________________________________________________

___________________________________________________________________________

4. Sosial Budaya :

___________________________________________________________________________

___________________________________________________________________________

E. RIWAYAT KELUARGA

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

F. PENGKAJIAN FISIK

1. Riwayat penyakit :

___________________________________________________________________________

___________________________________________________________________________

2. Kebiasaan yang berhubungan dengan status kesehatan:

CANDRA AGUS WIDODO/2231061014

Institut Teknologi Kesehatan Malang
Widya Cipta Husada 2022
 ___________________________________________________________________________

___________________________________________________________________________

3. Merokok :

___________________________________________________________________________

___________________________________________________________________________

4. Alkohol/obat-obatan:

___________________________________________________________________________

___________________________________________________________________________

5. Istirahat dan tidur :

___________________________________________________________________________

___________________________________________________________________________

6. Nutrisi :

___________________________________________________________________________

___________________________________________________________________________

7. Eliminasi :

___________________________________________________________________________

___________________________________________________________________________

8. Orientasi :

___________________________________________________________________________

___________________________________________________________________________

9. Tingkat aktifitas :

CANDRA AGUS WIDODO/2231061014

Institut Teknologi Kesehatan Malang
Widya Cipta Husada 2022
 ___________________________________________________________________________

___________________________________________________________________________

10. Tingkat energy :

___________________________________________________________________________

___________________________________________________________________________

G. ANALISA DATA

No Data Masalah Keperawayan

H. PRIORITAS DIAGNOSA KEPERAWATAN

CANDRA AGUS WIDODO/2231061014

Institut Teknologi Kesehatan Malang
Widya Cipta Husada 2022
 No Diagnosa Keperawatan

I. INTERVENSI KEPERAWATAN

No Diagnosa Outcome Intervensi

CANDRA AGUS WIDODO/2231061014

Institut Teknologi Kesehatan Malang
Widya Cipta Husada 2022
CANDRA AGUS WIDODO/2231061014
Institut Teknologi Kesehatan Malang
Widya Cipta Husada 2022
J. IMPLEMENTASI KEPERAWATAN

No Hari/tanggal Diagnosa Keperawatan Implementasi Evaluasi

CANDRA AGUS WIDODO/2231061014

Institut Teknologi Kesehatan Malang
Widya Cipta Husada 2022
CANDRA AGUS WIDODO/2231061014
Institut Teknologi Kesehatan Malang
Widya Cipta Husada 2022
CANDRA AGUS WIDODO/2231061014
Institut Teknologi Kesehatan Malang
Widya Cipta Husada 2022