U N I V E R S I T A S B O N D O W O S O

PROGRAM STUDI DIII KEPERAWATAN

JalanKhairil Anwar No.3B Tlp/Fax. (0332) 433015
Bondowoso
FORMAT PENGKAJIAN RESUME

Nama Mahasiswa : ........................................................................................................................

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Tanggal Praktik : ........................................................................................................................
PENGKAJIAN
A. Identitas klien
Nama : ..........................................................................................................
No. Register : ..........................................................................................................
Usia : ..........................................................................................................
Tanggal Masuk : ..........................................................................................................
Jenis kelamin : ..........................................................................................................
Tanggal Pengkajian : ..........................................................................................................
Alamat : ..........................................................................................................
Sumber informasi : ..........................................................................................................
Pekerjaan : ..........................................................................................................
Pendidikan : ..........................................................................................................
Agama : ..........................................................................................................
Suku/bangsa : ..........................................................................................................
Diagnosa Medis : ..........................................................................................................
B. Data Fokus
1. Data Subjektif
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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C. Data objektif
1. Tanda-Tanda Vital
Suhu : ................... °C lokasi : ......................
Nadi : ...................  /menit irama : ...................... pulsasi :
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Tekanan darah :................... mmHg lokasi : ......................
Frekuensi nafas:...................  /menit irama : ......................
Tinggi badan : ................... cm
Berat badan : SMRS ................... kg MRS .................... kg
2. Kepala
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3. Mata
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4. Telinga
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5. Hidung
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6. Mulut
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7. Leher
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8. Dada:
Jantung:
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Paru:
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9. Abdomen
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10. Urogenital
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11. Ekstremitas
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12. Kulit dan kuku

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13. Keadaan lokal
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D. Pemeriksaan Penunjang
1. Laboratorium
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2. Photo
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3. Lain-lain
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E. Terapi
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 ANALISA DATA
Nama Klien : ..................... Ruangan/kamar : ..............................
Umur : ..................... No. RM : ..............................

TGL/JAM DATA ETIOLOGI MASALAH

 DIAGNOSA KEPERAWATAN BERDASARKAN URUTAN PRIORITAS
Nama Klien : ..................... Ruangan/kamar : ..............................
Umur : ..................... No. RM : ..............................

NO TGL/JAM DIAGNOSA KEPERAWATAN PARAF

 RENCANA TINDAKAN KEPERAWATAN

TGL/ DIAGNOSA TUJUAN DAN RENCANA TINDAKAN RASIONAL PARAF

JAM KEPERAWATAN KRITERIA HASIL
 IMPLEMENTASI

NO. DX
TANGGAL / JAM IMPLEMENTASI PARAF
KEP
 EVALUASI

NO. DX
TANGGAL / JAM EVALUASI PARAF
KEP