FORMAT UJIAN AKHIR KEPERAWATAN JIWA

Nama : ..............................................                           Ruang   : ...........................

Umur : .............................................                            No Reg : .........................

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

I. PENGKAJIAN

Alasan masuk : ......................................................................................................................

Keluhan utama saat ini : .......................................................................................................

1.  Riwayat kesehatan

Riwayat sakit saat ini :..........................................................................................................

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Riwayat penyakit terdahulu : ................................................................................................

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Riwayat penyakit atau trauma sejak masih kecil :  ...............................................................

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2. Psikososial

1. Konsep diri :

a. Gambaran diri : .................................................................................................................

b. Peran  : .............................................................................................................................

c. Ideal diri : .........................................................................................................................

d. Harga diri : .......................................................................................................................

e. Identitas diri : ...................................................................................................................

2. Hubungan sosial selama di rumah sakit

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   3. Kondisi spiritual : ......................................................................................................

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3. Status Mental

1. Penampilan : ...................................................................................................................

   2. Proses pikir : ..............................................................................................................

   3. Isi pikir       : ...................................................................................................................

   4. Tingkat kesadaran :  ............................................................................................. ........

   5. Disorientasi : ...............................................................................................................

   6. Memori       : ...................................................................................................................

   7. Tingkat konsentrasi : ......................................................................................................

   8.  Kemampuan menilai :  ..................................................................................................

   9. Daya tilik diri : ...............................................................................................................

4. Mekanisme koping : .....................................................................................................

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5. Pemeriksaan fisik (Head to toe) : ...................................................................................

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6. Kemampuan merawat diri :   ........................................................................................

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7. Kegiatan sehari-hari selama di rumah sakit : ..............................................................

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8. Aspek medik

     a. Diagnosa medik : .......................................................................................................

     b. Terapi obat  :  .............................................................................................................

  

 II. ANALISA DATA

III. POHON MASALAH

IV. DIAGNOSA KEPERAWATAN

V. RENCANA KEPERAWATAN

VI. EVALUASI/CATATAN PERKEMBANGAN