ASUHAN KEPERAWATAN

KEGAWAT DARURATAN PSIKIATRIA. Identitas

Nama klien

: ............................................................... Jenis kelamin

: ............................................................... Umur

: ............................................................... Alamat

: ............................................................... No RM

: ............................................................... Tanggal Masuk

: ............................................................... Nama Penanggung Jawab: ............................................................... Alamat Penanggung Jawab: ............................................................... Hubungan dengan klien: ...............................................................B. Riwayat Penyakit

1. Alasan Masuk................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Riwayat Penyakit

Riwayat penyakit sebelum ................................................................................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Riwayat penyakit sesudah ................................................................................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................C. Diagnosis Medis Axis I

:.. Axis II

:. Axis III

:. Axis IV

:. Axis V

:.D. Therapi................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................E. Tahap Penanganan

1. Tahap Penanganan:

2. Skor

: 3. Tujuan Penanganan: .

4. Prinsip Penanganan 5. Hal yang dievaluasi: F. Status Mental

1. Persepsi sensori: 2. Proses berpikir: 3. Isi Pikir

: 4. Alam perasaan

: 5. Afek

: 6. Tingkat kesadaran: 7. Daya tarik diri

: G. Psikomotorik

1. Aktivitas

: 2. Pembicaraan

: 3. Interaksi wawancara: 4. Penampilan

: 5. Pola Nutrisi

: 6. Pola Tidur

: H. Analisa Data

DataMasalah Keperawatan

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I. Diagnosa Keperawatan1. ........................................................................................................................................... ...........................................................................................................................................2. ........................................................................................................................................... ...........................................................................................................................................3. ........................................................................................................................................... ...........................................................................................................................................4. ........................................................................................................................................... ...........................................................................................................................................J. Rencana dan Intervensi Keperawatan................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................K. Implementasi dan Evaluasi

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