PROGRAM PENDIDIKAN PROFESI NERS STIKES WIDYAGAMA HUSADA

FORMAT PENGKAJIAN RESUME KASUS KELOLAAN HARIAN

KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :
NIM :
Tempat Pengkajian :
Tanggal :

Identitas Klien
Nama : No. RM :
Umur : Pekerjaan :
Jenis : Status Perkawinan :
Kelamin
Agama : Tanggal MRS :
Pendidikan : Tanggal Pengkajian :
Alamat : Sumber Informasi :
Diagnosa
Medis :

Proses keperawatan
a. Pre operasi ( Ruang persiapan operasi)
1) Data focus
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2) Diagnosa keperawatan
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3) Evaluasi
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b. Intra operasi (Ruang Operasi)
1) Data Fokus
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2) Diagnosa keperawatan
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3) Intervensi /Implementasi
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4) Evaluasi
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c. Post operasi (Recovery Room)

1) Data Fokus
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2) Diagnosa keperawatan
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3) Intervensi /Implementasi
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4) Evaluasi
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Denpasar, 2013
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