RESUME KEPERAWATAN

Tanggal pengkajian :
Nama Pengkaji :
Ruang :
Waktu pengkajian :
A. Identitas
1. Identitas Klien
Nama :
Tanggal lahir :
Umur :
Jenis Kelamin :
BB :
PB/TB :
Alamat :
Agama :
Pendidikan :
Suku bangsa :
Tanggal masuk :
No. RM :
Diagnosa Medik :
2. Identitas penanggung jawab
Nama :
Umur :
Jenis kelamin :
Alamat :
Agama :
Pendidikan :
Pekerjaan :
Hubungan dengan klien:
3. Pengkajian Fokus
a. Keluhan Utama
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b. Riwayat Kesehatan
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c. Pengkajian Fungsional
1) Oksigenasi
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2) Cairan Dan Elektrolit
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3) Nutrisi
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4) Aman Dan Nyaman
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5) Eliminasi
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6) Aktifitas Dan Istirahat
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7) Psikologi
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8) Komunikasi
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9) Seksual
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10) Nilai Dan Keyakinan
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11) Belajar
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d. Px. Fisik
1) Sistem Pernapasan
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2) Sistem Kardiovaskuler
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3) Sistem Persyarafan
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4) Sistem Perkemihan
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5) Sistem Pencernaan
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6) Sistem Muskuluskletal
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7) Sistem Endokrin
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 8) Sistem Sensori Persepsi/ Pengimdreaan
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9) Sistem Integument
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10) Sistem Imun Dan Hematologi
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11) Sistem Reproduksi
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e. Px. Penunjang
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 ANALISA DATA

Nama Klien : ____________________

Ruang : ____________________

TGL/JAM DATA PROBLEM ETIOLOGI

PRIORITASDIAGNOSA KEPERAWATAN

Hari, tanggal : ___________________________

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