RESUME KEPERAWATAN

Nama Mahasiswa : Makiah

Npm : 1814901210161
Ruangan : Poliklinik Jiwa

Nama Klien :
Umur/Tanggal lahir :
Diagnosa Medis :
Tanggal Pengkajian :

Riwayat Keluhan Saat Pengkajian

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Data Fokus :
1. Keluhan Utama
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2. Faktor Presipitasi
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3. Faktor Predisposisi
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4. Data Subjektif
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5. Data Objektif
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6. Data Penunjang
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Analisis Data
Data Problem
Data Subjektif:

Data Objektif:

7. Diagnosa Keperawatan
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8. Prioritas Masalah
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9. Perencanaan
a. Tujuan
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b. Kriteria Hasil (Outcomes)
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c. Rencana Tindakan (Intervensi)

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10. Implementasi dan Evaluasi
Waktu
Implementasi Evaluasi Paraf
(Hari/Tanggal/Jam)
DS:

Makiah, S.Kep

DO:

Diagnosa Keperawatan:

Tindakan:
 Banjarmasin, September 2019

Preseptor Akademik, Preseptor Klinik,

(M.Anwari, Ns., M.Kep) (Yulita Puji Hastuti, S.Kep., Ns)