RESUME KEPERAWATAN

GAWAT DARURAT, KLIEN DENGAN ..........................................................................

PROGRAM PROFESI NERS SARI MULIA BANJARMASIN

I. IDENTITAS KLIEN
1. Nama : ......................................................................................
2. Jenis Kelamin : ......................................................................................
3. Umur : ......................................................................................
4. Pendidikan : ......................................................................................
5. Pekerjaan : ......................................................................................
6. Alamat : ......................................................................................
7. Status Perkawinan : ......................................................................................
8. Agama : ......................................................................................
9. Suku/Bangsa : ......................................................................................
10. Tanggal Masuk RS : ......................................................................................
11. Diagnosa Medis : ......................................................................................
12. Nomor Rekam Medik : ......................................................................................

II. RIWAYAT KESEHATAN

1. Keluhan Utama
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2. Riwayat Penyakit Sekarang
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3. Riwayat Penyakit Dahulu
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4. Riwayat Penyakit Keluarga
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III. PENGKAJIAN PRIMER/TRIASE

1. Airway : ..............................................................................................
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2. Breathing : ..............................................................................................
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3. Circulation : ...........................................................................................
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4 Disability : ..............................................................................................
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IV. RIWAYAT KESEHATAN (SAMPLE)

1. S : ....................................................................................................................
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2. A : .....................................................................................................................
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3. M : .....................................................................................................................
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4. P : .....................................................................................................................
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5. L : .....................................................................................................................
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6. E : .....................................................................................................................
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V. DATA FOKUS
1. Inspeksi : .........................................................................................................
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2. Palpasi : .........................................................................................................
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3. Perkusi : .......................................................................................................
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4. Auskultasi : .........................................................................................................
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INTERVENSI DAN IMPLEMENTASI DAN EVALUASI

Data Diagnosa Planning (NOC) Intervensi (NIC) Rasional Implementasi Evaluasi

Keperawata
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