PROGRAM STUDI S1 KEPERAWATAN TAHAP PROFESI NERS

FAKULTAS KEPERAWATAN DAN ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH BANJARMASIN
RESUM KEPERAWATAN
STASE ANAK
2016
CI

NAMA
NPM
RUANGAN

CT

: AISYAH S.Kep
: 14142013005
: ANAK (TULIP II A) RSUD ULIN

A. PENGKAJIAN
1. Identitas klien
Nama

Umur

Alamat

Diagnosa Medis

Tanggal Pengkajian

2. Data Fokus
a. Keluhan Utama
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___
b. Inspeksi
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
c. Auskultasi
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
d. Perkusi
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
e. Palpasi
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
f. Data Tambahan
TD :
mmhg
Respirasi :
x/m
Nadi :

x/m

Temperatur :

B. ASUHAN KEPERAWATAN
1. Analisa Data
DATA

PROBLEM

ETIOLOGI

2. Diagnosa Keperawatan
_______________________________________________________________________________________
_______________________________________________________________________________________
Tujuan_________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Intervensi Keperawatan
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_
_____________________________________________________________________________________
Implementasi Keperawatan
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
3. Evaluasi Keperawatan
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____________________________________________
______________________________________________________________________________________
___

____________________________________________________________________________________________
___________
PROGRAM STUDI S1 KEPERAWATAN TAHAP PROFESI NERS
FAKULTAS KEPERAWATAN DAN ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH BANJARMASIN
RESUM KEPERAWATAN
STASE ANAK
2016
CI

NAMA
NPM
RUANGAN

CT

: AISYAHS.Kep
: 14142013005
: ANAK (TULIP II A) RSUD ULIN

A. PENGKAJIAN
1. Identitas klien
Nama

Tanggal Lahir

Jenis Kelamin

Umur

Alamat

Diagnosa Medis

Tanggal MRS

Tanggal Pengkajian

2. Keluhan Utama Saat Ini

_______________________________________________________________________________________
_______________________________________________________________________________________
3. Data Fokus
a. Inspeksi
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
b. Auskultasi
_____________________________________________________________________________________
____________________________________________________________________________________
c. Perkusi

_____________________________________________________________________________________
_____________________________________________________________________________________
d. Palpasi
_____________________________________________________________________________________
_____________________________________________________________________________________
g. Data Tambahan
TD :

mmhg

Respirasi :

x/m

Nadi :

x/m

Temperatur :

0C

Antropometri Data
BB :

Kg

TB :

BBI : (

x 2) + =

cm

_____________________________________________________________________________________
_____________________________________________________________________________________
B. ASUHAN KEPERAWATAN
Analisa Data
DATA

PROBLEM

ETIOLOGI

Diagnosa Keperawatan
_______________________________________________________________________________________
_______________________________________________________________________________________
Intervensi Keperawatan
DIAGNOSA
KEP

TUJUAN

INTERVENSI

RASIONAL

Implementasi dan Evaluasi Keperawatan

HARI
/ TGL /
JAM

DIAGNOSA
KEP

IMPLEMENTASI

EVALUASI

PROGRAM STUDI S1 KEPERAWATAN TAHAP PROFESI NERS

FAKULTAS KEPERAWATAN DAN ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH BANJARMASIN
RESUM KEPERAWATAN
STASE ANAK
2016
CI

NAMA
NPM
RUANGAN

CT

: AISYAH S.Kep
: 14142013005
: HEMATOLOGI DAN ONKOLOGI (TULIP III A) RSUD ULIN

A. PENGKAJIAN
1. Identitas klien
Nama

Tanggal Lahir

Jenis Kelamin

Umur

Alamat

Diagnosa Medis

Tanggal Pengkajian

2. Keluhan Utama Saat Ini

_______________________________________________________________________________________
_______________________________________________________________________________________
3. Data Fokus
a. Inspeksi
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
b. Auskultasi
_____________________________________________________________________________________
____________________________________________________________________________________
c. Perkusi
_____________________________________________________________________________________
_____________________________________________________________________________________
d. Palpasi
_____________________________________________________________________________________
______
_______________________________________________________________________________

h. Data Tambahan
TD :

mmhg

Respirasi :

x/m

Nadi :

x/m

Temperatur :

0C

Antropometri Data
BB :

Kg

TB :

BBI : (

x 2) + =

cm

_____________________________________________________________________________________
_____________________________________________________________________________________
A. ASUHAN KEPERAWATAN
Analisa Data
DATA

PROBLEM

ETIOLOGI

Diagnosa Keperawatan
_______________________________________________________________________________________
_

______________________________________________________________________________________

Intervensi Keperawatan
DIAGNOSA
KEP

NOC

NIC

Implementasi dan Evaluasi Keperawatan

HARI
/ TGL /
JAM

DIAGNOSA
KEP

IMPLEMENTASI

EVALUASI