RESUME KEPERAWATAN

PADA DENGAN GANGGUAN PEMENUHAN KEBUTUHAN

DI RUANG RUMAH SAKIT dr. Asmir-DKT Salatiga

1. PENGKAJIAN
A. IDENTITAS KLIEN
Nama (Inisial) :
L/P :
Umur :
Alamat :
Pendidikan :
Agama :
No. RM :
Tgl Pengkajian :

B. ALASAN MASUK
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C. PEMERIKSAAN FISIK
Keadaan umum :
TD :
Nadi :
Respirasi :
Suhu :
Keluhan fisik :

D. DATA FOKUS
DATA SUBYEKTIF DATA OBYEKTIF

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E. ANALISA DATA
N SYMPTOM ETIOLOGI PROBLEM
o
1. Subyektif
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Obyektif
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 2. Subyektif
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Obyektif
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F. DAFTAR DIAGNOSA KEPERAWATAN (PRIORITAS)

1. ............................................................................................................................
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G. RENCANA INTERVENSI KEPERAWATAN

NO DIAGNOSA NOC NIC

TGL/JAM KEPERAWATAN

H. IMPLEMENTASI DAN EVALUASI KEPERAWATAN

NO DIAGNOSA IMPLEMENTASI EVALUASI
TGL/JAM KEPERAWATAN
S :
O:
A:
P:
- Pasien :
- Perawat:
I. RENCANA TINDAK LANJUT