Laporan Resume
Laporan Resume
Pengkajian
Nama Mahasiswa : Siti Nuur Jannah, S.Kep
NIM : 1630913320038
Tempat Praktek : IGD Kandungan RSUD Dr. H. Moch. Ansari Saleh
Tanggal Praktek : 6 - 11 Maret 2016
Data Demografi
Nama Klien : Nama Suami :
Umur Klien : Umur Suami :
Jenis Kelamin : Alamat :
Status Perkawinan : Pekerjaan :
Agama : Diagnosa Medik :
Suku : Tgl MRS :
Pendidikan : Tgl Pengkajian :
Riwayat Ginekologi :
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Riwayat Obstetri :
G P A HPL :
HPHT : Usia Kehamilan :
Keluhan yang muncul selama kehamilan :
1. Trimester I :
2. Trimester II :
3. Trimester III :
Eliminasi
BAK :
BAB :
Aktivitas dan latihan :
Aktivitas selama hamil :
Keluhan dalam beraktivitas :
Keluarga Berencana
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Pemeriksaan Fisik
Kaji vital sign
Tekanan darah : mmHg
Nadi : x/menit
Temperatur : C
Respirasi rate : x/menit
Ukur BB dan TB : kg dan cm
Inspeksi Kulit
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Inspeksi kuku dan rambut
Kepala dan leher
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Telinga
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Perkusi :
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Auskultasi :
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Payudara
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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Abdomen
Inspeksi :
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Palpasi :
Leopold I................................................................................................
Leopold II...............................................................................................
Leopold III.............................................................................................
Leopold IV.............................................................................................
Tinggi Fundus Uteri :
Auskultasi :
(Frekuensi, kekuatan, kesimpulan)
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Tafsiran berat janin :
Genitalia
Inspeksi :
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Palpasi :
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Vaskularisasi perifir
Inspeksi :
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Muskuloskeletal
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Neurologik
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Data Laboratorium
Tanggal dan Hasil pemeriksaan dan nilai normal Interpretasi
jenis
pemeriksaan
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Pengobatan
Tanggal Jenis terapi Rute terapi Dosis Indikasi terapi
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Analisa Data
Data Kemungkinan Penyebab Masalah
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Diagnosa Keperawatan
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Rencana, Implementasi, Evaluasi
Tanggal Diagnosa
Tujuan Intervensi Implementasi Evaluasi
/ Jam Keperawatan
Banjarmasin,………………….. 2017