RESUME KEPERAWATAN PADA …………………

DENGAN GANGGUAN…………………………………………………………………..
PADA KASUS …………………………………………….
DI RUANG…………………………RSUD KOTA MATARAM
Tanggal…………………………………

I. PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama : ......................................................................................... ......
Umur : ......................................................................................... ......
Agama : ......................................................................................... ......
Jenis Kelamin : ........................................................................................... ....
Status : ........................................................................................... ....
Pendidikan :............................................................................................ ....
Pekerjaan : ............................................................................................ ...
Suku Bangsa :............................................................................................ ....
Alamat : .......................................................................................... .....
Tanggal Masuk : ........................................................................................... ....
Tanggal Pengkajian : ........................................................................................... ....
No. Register : ............................................................................................. ..
Diagnosa Medis : ............................................................................................ ...

b. Identitas Penanggung Jawab

Nama : ............................................................................................ ...
Umur : ............................................................................................. ..
Hub. Dengan Pasien : ........................................................................................... ...
Pekerjaan : ............................................................................................. ..
Alamat : .............................................................................................. .
2. Riwayat Perjalanan Penyakit

a. Keluhan Utama
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b. Riwayat Penyakit sekarang

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c. Riwayat Penyakit Dahulu

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d. Riwayat penyakit Keluarga

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3. Pemeriksaan Fisik
 Pengkajian (Data Fokus)

Keadaan umum :..................................................

Kesadaran :..........................................................

GCS :........(E....V....M....)

Pemeriksaan Umum :
Air way (A) Bhreating (B) Circulation (C) Disposure (D) Ket.
 Paten Gerakan dada Denyut Nadi  Alert
 Obstruksi  Simetris  Ada  Voice
Partial  Asimetris  Tidak  Pain
 Obstruksi Tipe Pernafasan Kulit/mukosa  Unconscious
total  Normal  Normal
 Suara  Abnormal  Pucat
nafas Laju Pernafasan  Ikterik
tambahan  Normal  Sianosis
 Abnormal  Berkeringat
Akral
 Dingin
 Hangat
CRT
 <2 detik
 >2 detik

 Data Subyektif
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 Data Obyektif
a. Sistem................................
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b. Sistem..................................
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c. Sistem......................................
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4. Terapi dan Diet

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3. ANALISA DATA
A. Tabel Analisa Data
DATA Etiologi MASALAH
B. Tabel Daftar Diagnosa Keperawatan

NO TANGGAL / DIAGNOSA KEPERAWATAN TANGGAL Ttd

JAM TERATASI
DITEMUKAN
 C. Rencana Tindakan Keperawatan

Rencana Perawatan Ttd

Hari/ No
Tujuan dan Kriteria
Tgl Dx Intervensi Rasional
Hasil
 D. Implementasi Keperawatan
Hari/ Ttd
No Dx Tindakan Keperawatan Evaluasi proses
Tgl/Jam
E. Evaluasi Keperawatan
Hari/Tgl
No No. Dx Evaluasi Ttd
Jam