FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH PONOROGO

Jl. Budi Utomo No. 10, Telp. (0352) 481124 Ponorogo – 63471

RESUME ASUHAN KEPERAWATAN PADA KLIEN TN/NY .....................

DENGAN ..........................................................
DI ...................................................................................
I.PENGKAJIAN
a. Identitas Klien
Nama : .....................................................
Umur : .....................................................
No. Register : .....................................................
Agama : .....................................................
Alamat : .....................................................
Pendidikan : .....................................................
Pekerjaan : .....................................................
Tanggal masuk RS : .....................................................
Diagnosa Medis : .....................................................

b. Identitas Penanggungjawab
Nama : .....................................................
Umur : .....................................................
Agama : .....................................................
Alamat : .....................................................
Pendidikan : .....................................................
Pekerjaan : .....................................................
Hubungan dengan klien : .....................................................
II.KELUHAN UTAMA
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III.RIWAYAT PENYAKIT SEKARANG
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IV.RIWAYAT PENYAKIT DAHULU
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V.PEMERIKSAAN FISIK FOKUS

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VI.DATA ANALISA

Nama : ................................... No. Reg. : ...................................

Umur : ...................................
No. Tanggal Data Penyebab Masalah

VII. DAFTAR MASALAH/DAFTAR DIAGNOSA KEPERAWATAN

(Disusun berdasarkan Prioritas Masalah)

1.
2.
3.
4.
5.
VIII. RENCANA ASUHAN KEPERAWATAN

Nama : ................................... No. Reg. : ...................................

Umur : ...................................
No. Diagnosa Luaran Intervensi
Keperawatan Dan Kriteria hasil
 FAKULTAS ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH PONOROGO
Jl. Budi Utomo No. 10, Telp. (0352) 481124 Ponorogo – 63471

RESUME ASUHAN KEPERAWATAN PADA KLIEN TN/NY .....................

DENGAN ..........................................................
DI IGD ...................................................................................

IX.PENGKAJIAN
c. Identitas Klien
Nama : .....................................................
Umur : .....................................................
No. Register : .....................................................
Agama : .....................................................
Alamat : .....................................................
Pendidikan : .....................................................
Pekerjaan : .....................................................
Tanggal masuk RS : .....................................................
Diagnosa Medis : .....................................................

d. Identitas Penanggungjawab
Nama : .....................................................
Umur : .....................................................
Agama : .....................................................
Alamat : .....................................................
Pendidikan : .....................................................
Pekerjaan : .....................................................
Hubungan dengan klien : .....................................................

X.SURVEY PRIMER
a. AIRWAY
 Sumbatan : Benda asing, lidah, sputum, darah
 Posisi kepala : .............................
b. BREATHING
 Batuk : produktif, tidak produktif, nyeri dada, ekxpansi paru
  Pola nafas : dalam, dangkal, cepat, lambat, sesak nafas
 Frekwensi nafas : berapa kali/menit, teratur/tidak, apneu
 Suara nafas : vesikuler, wheezing, ronchi, crackels
 Dispneu : saat aktivitas, tanpa aktivitas, tanpa alat tambahan
c. CIRCULATION
 Tekanan darah, suhu
 Nadi : kuat/lemah, teratur/tidak teratur, aritmia
 Ekstremitas dingin
 Mimisan, epistaksis
 Edema
 Gemeteran kesemutan
 Nyeri dada
 CRT : 2-3 detik, > 3 detik

d. DISABILITY
 GCS : 3-8, 9-12, 13-15
 Reflek pupil
 Neurosensorik/musculoskeletal : spasme otot, parestesia, perubahan pergerakan, kekuatan otot
e. EXPOSURE
 Kerusakan jaringan
 Fraktur, krepitasi
 Dislokasi, luxatio
 Luka baker
 Edema
XI.SURVEY SKUNDER
a. Keadaan umum klien
b. Riwayat penyakit sekarang
Keadaan klien saat dikaji
c. Riwayat kesehatan masa lalu
Riwayat masuk rumah sakit klien
XII.PEMERIKSAAN PENUNJANG
 Pemeriksaan laboratorium
 X-Ray, USG, EKG, ECG
XIII.DATA TAMBAHAN
  Terapi cairan yang diberikan
 Obat-obatan yang diberikan

XIV.DATA ANALISA

Nama : ................................... No. Reg. : ...................................

Umur : ...................................
No. Tanggal Data Penyebab Masalah

XV. DAFTAR MASALAH/DAFTAR DIAGNOSA KEPERAWATAN

 (Disusun berdasarkan Prioritas Masalah)
1.
2.
3.
4.
5.

XVI. RENCANA ASUHAN KEPERAWATAN

Nama : ................................... No. Reg. : ...................................

Umur : ...................................
No. Diagnosa Luaran Intervensi
Keperawatan Dan Kriteria hasil