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RESUME KEPERAWATAN PADA NY.

M DENGAN GANGGUAN RASA NYAMAN

DI DUSUN KARANG PANDE DESA BANYUMULEK

Tanggal/ Tempat Pengkajian : ............................


Nama Pengkaji : ............................

A. Data biografi

Nama : .......................................................................... L / P
Tempat & Tanggal lahir : ................................... Gol. Darah : O / A / B / AB
Pendidikan terakhir : ..........................................................................................
Agama : Islam/ Protestan/ Katolik/ Hindu/ Budha/ Konghucu/ LL
Status Perkawinan : Kawin / Belum / Janda / Duda (Cerai : Hidup / Mati )
TB/BB : ......................... Cm/ ................. Kg
Penampilan : ...............................................................................................
Ciri-ciri tubuh : ......................................
Alamat : .......................................................................................
.......................................................................................Telp. ........................................
Orang yang dekat dihubungi : .......................................................................................
Hubungan dengan usila : .......................................................................................
Alamat : .......................................................................................

B. Alasan Masuk
1. Keluhan Saat Dikaji
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2. Data
Fokus ...........................................................................................................................................
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C. Analisa Data

Data Interpretasi Masalah


(sign / Symptom) (Etiologi) (Problem)

D. Diagnosa Keperawatan
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E. Rencana Keperawatan

No. Hari/Tgl/Jam Diagnosa TUJUAN INTERVENSI RASIONAL


Perawatan

F. Implementasi dan Evaluasi Keperawatan


HARI/TGL DX. KEP. TINDAKAN KEPERAWATAN EVALUASI TINDAKAN TTD/NAMA
PUKUL PERAWAT
S:

O:

A:

P: