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LAPORAN RESUME
ASUHAN KEPERAWATAN JIWA
INSTALASI GAWAT DARURAT RUMAH SAKIT JIWA MENUR
SURABAYA
Doc . RESUME/ IGD RSJM / S1 – KEPERAWATAN & D III / PJMK JIWA
A. PENGKAJIAN
1. IDENTITAS PASIEN a. Nama Pasien : ............................................, Umur : .............th,( L ) / ( P ) b. Register : ........................................, Tanggal : ................................ c. Agama : ............................................................................................. d. Status : ( Menikah ) / ( Tidak menikah ) , Pendidikan : ............. e. Pekerjaan : ........................................................................................... f. Alamat : ............................................................................................
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2. KELUHAN UTAMA / ALASAN MASUK ……………………………………………………………..…………………………………………………………………………………………..………………………………………………………………………………………………………………………………...........................................................……..……….......................................................……
3. RIWAYAT PENYAKIT SEKARANG ( KRONOLOGIS ) ………………………………………………..…………………………………………… ………………………………………………..……………………………………………………………………………………………..…………………………………………………………………………………………..……………………………………………………..……................................................................................................................……… …………………………………………………………..………………………………………………………………………………………………..………………………………………………………………………………………………………………………...............................................................................................................…………..……...……… ……………………................………………………………..............…………………..........................................................................................................................................................................................................................................................................................................................................................................................................................................… ........................................................................................................................................................................................................................................................................................… ........................................................................................................................................................................................................................................................................................…
B. STATUS MENTAL 1. KEADAAN UMUM
…………………………..……………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………..................................................................................................................……..…………… ................................................................................................................……..…………… ................................................................................................................……..…………… ................................................................................................................……..……………
2. PENAMPILAN ……………………..……………………………………………………………………………………………………………………………………………………...........................................................…………..………......................................................................…… …………………………………………………......………………………………………
01
LAPORAN RESUME
ASUHAN KEPERAWATAN JIWA
INSTALASI GAWAT DARURAT RUMAH SAKIT JIWA MENUR
SURABAYA
Doc . RESUME/ IGD RSJM / S1 – KEPERAWATAN & D III / PJMK JIWA
3. KESADARAN …………………………………………………......……………………………………… …………………………………………………......……………………………………… …………………………………………………......……………………………………… …………………………………………………......……………………………………… …………………………………………………......………………………………………
4. PEMBICARAAN …………………………………………………......……………………………………… …………………………………………………......……………………………………… …………………………………………………......……………………………………… …………………………………………………......………………………………………
C. KEADAAN AFEK …………………………………………………......……………………………………… …………………………………………………......……………………………………… …………………………………………………......……………………………………… …………………………………………………......……………………………………… …………………………………………………......……………………………………… …………………………………………………......………………………………………
D. PROSES BERPIKIR …………………………………………………...........……………………………………… …………………………………………………...........……………………………………… …………………………………………………...........……………………………………… …………………………………………………...........……………………………………… …………………………………………………...........………………………………………
E. PERSEPSI …………………………………………………...........……………………………………… …………………………………………………...........……………………………………… …………………………………………………...........……………………………………… …………………………………………………...........……………………………………… …………………………………………………...........………………………………………
F. DIAGNOSA KEPERAWATAN ………………………………….......................................................…………………...…… ……………………………………,,,,…………………………………………………..…… ………………………………………,,,,………………………………………………..……
G. RENCANA KEPERAWATAN 1. TUJUAN UMUM
………………………………………………..……………………………………………………………………………………………..…………………………………………………………………………………………..……………………………………………………..……................................................................................................................……… …………………………………………………………..………………………………………………………………………………………………..………………………………………………………………………………………………………………………...............................................................................................................…………..……...………
02
LAPORAN RESUME
ASUHAN KEPERAWATAN JIWA
INSTALASI GAWAT DARURAT RUMAH SAKIT JIWA MENUR
SURABAYA
Doc . RESUME/ IGD RSJM / S1 – KEPERAWATAN & D III / PJMK JIWA
2. TUJUAN KHUSUS ………………………………………………..……………………………………………………………………………………………..…………………………………………………………………………………………..……………………………………………………..……............................................................................................................ …………………………………………………………..………………………………………………………………………………………………..………………………………………………………………………………………………………………………...............................................................................................................…………..……...
D. TINDAKAN KEPERAWATAN ………………………………………………..……………………………………………………………………………………………..…………………………………………………………………………………………..…………………………………………………….. …………………………………………………………..…………………………………………………………….....…………………………………..……………………………… ……………………….....…………………………………..……………………………… ……………………….....…………………………………..……………………………… ……………………….....…………………………………..……………………………… ……………………….....…………………………………..……………………………… ……………………….....…………………………………..……………………………… ……………………….....…………………………………..……………………………… ……………………….....…………………………………..……………………………… ……………………….....…………………………………..……………………………… ……………………….....…………………………………..……………………………… ……………………….....…………………………………..………………………………
E. TERAPI ………………………………………………..……………………………………………………………………………………………..…………………………………………………………………………………………..……………………………………………………..……................................................................................................................……..................
F. EVALUASI
………………………………………………..……………………………………………………………………………………………..…………………………………………………………………………………………..……………………………………………………..……...................................................................................................................................………
Surabaya, ................. Mengetahui Mahasiswa Kepala Ruangan Instalasi Gawat Darurat Rumah Sakit Jiwa Menur Surabaya
Arif Soeprijono, Skep. Ns Nim : Nip : 19710722 199603 1 0033
03
LAPORAN RESUME
ASUHAN KEPERAWATAN JIWA
INSTALASI GAWAT DARURAT RUMAH SAKIT JIWA MENUR
SURABAYA
Doc . RESUME/ IGD RSJM / S1 – KEPERAWATAN & D III / PJMK JIWA
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