UNIVERSITAS JEMBER

KUMPULAN RESUME KASUS KELOLAAN HARIAN DI RUANG

________ RUMAH SAKIT UMUM DAERAH/DAERAH __________

OLEH:
_____________, S. Kep
NIM 1823111010__

PROGRAM STUDI PENDIDIKAN PROFESI NERS

FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
__________, 2018
 RESUME KASUS KELOLAAN HARIAN - 1

1. Identitas Pasien
a. Nama :
b. Tanggal lahir :
c. Jenis kelamin :
d. RM :
e. Diagnosa Medis :
f. Tanggal masuk RS : jam : WIB
g. Tanggal pengkajian : jam : WIB

2. RIWAYAT KESEHATAN
a. Keluhan utama:

b. Riwayat kesehatan sekarang:

c. Riwayat kesehatan klien sebelumnya:

d. Pengkajian head to toe (DATA FOKUS)

e. Pemeriksaan Diagnostik/Pemeriksaan Penunjang

3. CATATAN PERAWATAN & PERKEMBANGAN KLIEN HERE AND NOW

S (Subjektif)
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O (Objektif)
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A (Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan DO)

Ex: ketidakefektifan pola nafas berhubungan dengan … ditandai dengan …
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P (Perencanaan)
Diagnosa NOC NIC
Keperawatan
1. Nama NIC
 2. 1.
3. dst 2.
Setelah dilakukan tindakan 3. dst
keperawatan ….. klien ….
dengan kriteria hasil:
1.
2.
3. dst
I (Implementasi)

Diagnosa Implementasi Paraf

Keperawatan
1.
2.
3. dst

E (Evaluasi):
S (Subjektif)
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O (Objektif)
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A (Analisa)
Ex : masalah ….. belum teratasi/teratasi sebagian/teratasi
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P (Perencanaan)
Ex: intervensi … dilanjutkan/intervensi dihentikan
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