LAPORAN KLIEN RESUME

DI POLI TUMBUH KEMBANG

RSUD ULIN BANJARMASIN
Tanggal 9 -14 Juni 2013

Oleh :
FARAH NUR ADILLAH, S.Kep
NIM I1B110034

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS LAMBUNG MANGKURAT
2014

LEMBAR PENGESAHAN
LAPORAN KLIEN RESUME
DI POLI TUMBUH KEMBANG
RSUD ULIN BANJARMASIN
Tanggal 9 - 14 Juni 2014

Oleh :
FARAH NUR ADILLAH, S.Kep
NIM I1B110034

Banjarmasin, Juni 2014

Mengetahui,
Pembimbing Akademik

Devi Rahmayanti,S.Kep,Ns
S.Kep, Ns., MM

Pembimbing Lahan

Rena Rasyidah,

LAPORAN RESUME KLIENDI POLI TUMBUH KEMBANG

Nama Mahasiswa
NIM
Kelompok

:.....................................................................................
:.....................................................................................
:.....................................................................................

I. IDENTITAS DATA
Nama
Umur
Jenis Kelamin
No. MRS
Nama Ayah/lbu
Pekerjaan Ayah/Ibu
Pendidikan Ayah/Ibu
Alamat / No. Telpon
Suku
Agama
Ruang
Diagnosa Medis

:..............................................................................................
:..............................................................................................
: .............................................................................................
: ..............................................................................................
:..............................................................................................
:..............................................................................................
:..............................................................................................
:..............................................................................................
...............................................................................................
:..............................................................................................
:..............................................................................................
: ..............................................................................................
: ..............................................................................................

II. ALASAN MASUK

III. RIWAYAT PENYAKIT

a. Keluhan Utama

b. Riwayat Penyakit Sekarang

c. Riwayat Penyakit Dahulu

d. Riwayat Penyakit Keluarga

IV.
DATA FOKUS
Inspeksi :
..
Palpasi :
..
Perkusi :
..
Auskultasi:
..
V. DATA TAMBAHAN
BB
=
TB
=
LK
=
LLA
=
VI.

DATA PENUNJANG
NCHS
a. BB/U
..
...
.......................................................................................................................................
b. TB/U

....
........................................................................................................................................
c. BB/TB

........................................................................................................................................
d. CDC 2000

....
.........................................................................................................................................

VII.

ANALISA DATA

DATA

ETIOLOGI
..
..
..
..
..
..
..
..
..

MASALAH
.
.
.
.
.
.
.
.
.

..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

VIII. RENCANA ASKEP

1. Diagnosa Keperawatan :..................
...................
...................
2. Tujuan

: ........
.......
.......
.......
.......

3. Kriteria Hasil

: ........
.......
.......
.......

4. Intervensi

: ........
.......
.......
.......
.......
.......
.......
.......
.......................................................................................................
.......................................................................................................

5. Implementasi

: ........
.......
.......
.......
.......
.......
.......
.......
.......................................................................................................
.......................................................................................................
.......................................................................................................

6. Evaluasi
S

............................................................................................................................
............................................................................................................................
............................................................................................................................
:

............................................................................................................................
............................................................................................................................
............................................................................................................................

Patofisiologi dan Web of Caution