RESUME KEPERAWATAN KLIEN……………….

DENGAN………………………
DIRUANG…………………. RSUD……………………..

I. PENGKAJIAN
Tanggal pengkajian ...................................................................................................................
Jam pengkajian ..........................................................................................................................
A. BIODATA
1. Klien
Nama : ...............................................................................................
Umur : ..............................................................................................
Alamat : ..............................................................................................
Agama : ..............................................................................................
Pendidikan : ..............................................................................................
Pekerjaan : ..............................................................................................
Status Pernikahan : ..............................................................................................
Tanggal masuk RS : ..............................................................................................
No. Rekam Medis : ..............................................................................................
Diagnosa Medis : ..............................................................................................
2. Penanggung Jawab
Nama : ..............................................................................................
Umur : ..............................................................................................
Alamat : ..............................................................................................
Hubungan dengan klien : .............................................................................................

B. Alasan Utama MRS

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C. Keluhan Utama
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D. Riwayat Kesehatan
1. Riwayat Kesehatan Sekarang
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2. Riwayat Penyakit Dahulu
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3. Riwayat Penyakit Keluarga
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E. Pemeriksaan Fisik
1. Keadaan Umum
Kesan penampilan klien ................................................................................................
Kesadaran ......................................................................................................................
GCS ...............................................................................................................................
Vital Sign .......................................................................................................................
TD................ mmHg, ND..........x/m, RS..........x/m, SH............ ...........................
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F. Pemeriksaan penunjang
PEMERIKSAAN HASIL NILAI SATUAN
RUJUKAN
HEMATOLOGI
Hemoglobin
Hematokrit
Lekosit
Trombosit
Eritrosit
MPV
PDW
INDEX
MCV
MCH
MCHC
HITUNG JENIS
Gran%
Limfosit%
Monosit%
Eosinofil%
Basofil%
Masa Pembekuan (CT)
Masa Perdarahan (BT)
Golongan Darah
KIMIA
GULA DARAH
Gula Darah Sewaktu
GINJAL
Creatinin
Ureum
G. Teraphy Medis
II. ANALISA DATA
Nama Klien : No. Register :
Umur : Diagnosa Medis :
DATA FOKUS ETIOLOGI PROBLEM
III. DIAGNOSA KEPERAWATAN
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IV. INTERVENSI
NO DX KEPERAWATAN TUJUAN INTERVENSI
V. IMPLEMENTASI
TGL JAM NO.DX IMPLEMENTASI RESPON TTD
VI. EVALUASI
TGL/JAM DX KEPERAWATAN EVALUASI TTD