laporan resume igd rsjm

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

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2. PENAMPILAN ……………………..……………………………………………………………………………………………………………………………………………………...........................................................…………..………......................................................................…… …………………………………………………......………………………………………

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LAPORAN RESUME

ASUHAN KEPERAWATAN JIWA

INSTALASI GAWAT DARURAT RUMAH SAKIT JIWA MENUR

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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

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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

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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