RESUME

Nama Mahasiswa : .......................................... Tgl Pengkajian : .................................

NIM : .......................................... Ruang Rawat : .................................

A. Identitas Pasien

Nama : ..........................................

Tanggal Lahir / Umur : ..........................................

Agama : ..........................................

Alamat : ..........................................

Diagnosa Medis : ..........................................

B. Keluhan Utama

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C. Riwayat Keluhan Utama

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D. Riwayat Penyakit Dahulu/ Riwayat Penyakit Keluarga

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Program Profesi Ners UNIVERSITAS SAM RATULANGI

E. Pemeriksaan Fisik

o Kesadaran

Skala Coma Glasgow : Respon Motorik ...... Jumlah

Respon Bicara ......
Respon Membuka Mata ......
Kesimpulan : .......................................

o Tanda-Tanda Vital

TD = ............... mmHg R = ............... kali/menit

N =............... kali/menit SB = ............... °C

o Pengukuran

BB = ............... kg

TB =............... cm

o Head To Toe

Kepala : ......................................................................................................
Mata : ......................................................................................................
Hidung : ......................................................................................................
Mulut : ......................................................................................................
Leher : ......................................................................................................
Dada : ......................................................................................................
Perut : ......................................................................................................
Kelamin : ......................................................................................................
Lengan atas : ......................................................................................................
Lengan bawah : ......................................................................................................
Anus : ......................................................................................................
Kulit : ......................................................................................................

Program Profesi Ners UNIVERSITAS SAM RATULANGI

F. Pemeriksaan Penunjang

G. Terapi Saat ini

Program Profesi Ners UNIVERSITAS SAM RATULANGI

 KLASIFIKASI DATA

DATA SUBJEKTIF DATA OBJEKTIF

Program Profesi Ners UNIVERSITAS SAM RATULANGI

 ANALISA DATA

DATA ETIOLOGI MASALAH

Program Profesi Ners UNIVERSITAS SAM RATULANGI

 DIAGNOSA KEPERAWATAN DAN PERENCANAAN KEPERAWATAN

Perencanaan Keperawatan
NO. Diagnosa Keperawatan
Tujuan (NOC) Intervensi (NIC) Rasional

Program Profesi Ners UNIVERSITAS SAM RATULANGI

 CATATAN PERKEMBANGAN

Tanggal/Ruangan :

No Dx Jam Implementasi Evaluasi

Program Profesi Ners UNIVERSITAS SAM RATULANGI

Program Profesi Ners UNIVERSITAS SAM RATULANGI