KUMPULAN LAPORAN

STASE KEPERAWATAN DASAR PROFESI

DI RUANG IGD
RSU SARI MULIA BANJARMASIN

Untuk Menyelesaikan Tugas Profesi Keperawatan Dasar Profesi

Program Profesi Ners

Disusun Oleh:

MELLYSA
11194561920055

PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS SARI MULIA
BANJARMASIN
2020
 LAPORAN PENDAHULUAN PNEUMONIA
DI RUANG IGD
RSU SARI MULIA BANJARMASIN

Untuk Menyelesaikan Tugas Profesi Keperawatan Dasar Profesi

Program Profesi Ners

Disusun Oleh:

MELLYSA
11194561920055

PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS SARI MULIA
BANJARMASIN
2020
 ASUHAN KEPERAWATAN DASAR PROFESI
PADA TN/ NY….. DENGAN ……………………
DI RUANG IGD
RSU SARI MULIA BANJARMASIN

Untuk Menyelesaikan Tugas Profesi Keperawatan Dasar Profesi

Program Profesi Ners

Disusun Oleh:

MELLYSA
11194561920055

PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS SARI MULIA
BANJARMASIN
2020
 RESUME KEPERAWATAN DASAR PROFESI
PADA NY.M DENGAN GASTRITIS
DI RUANG IGD
RSU SARI MULIA BANJARMASIN

Untuk Menyelesaikan Tugas Profesi Keperawatan Dasar Profesi

Program Profesi Ners

Disusun Oleh:

MELLYSA
11194561920055

PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS SARI MULIA
BANJARMASIN
2020
 RESUME KEPERAWATAN DASAR PROFESI
PADA TN/ NY….. DENGAN ……………………
DI RUANG IGD
RSU SARI MULIA BANJARMASIN

Untuk Menyelesaikan Tugas Profesi Keperawatan Dasar Profesi

Program Profesi Ners

Disusun Oleh:

MELLYSA
11194561920055

PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS SARI MULIA
BANJARMASIN
2020
 LEMBAR PERSETUJUAN

LAPORAN PENDAHULUAN PNEUMONIA

DI RUANG IGD RUMAH SAKIT UMUM SARI MULIA BANJARMASIN

Tanggal 12 September 2020

Disusun oleh :

MELLYSA
11194561920055

Banjarmasin, 12 September 2020

Mengetahui,

Preseptor Akademik, (PA) Preseptor Klinik, (PK)

M. Riduansyah, S.Kep., Ns., M.Kep M. Agus Abdi, S.Kep., Ns

NIK. 1166072017105 NIK.
 LEMBAR PERSETUJUAN

ASUHAN KEPERAWATAN PADA NY. Y DENGAN HIPERTENSI

DI RUANG IGD RUMAH SAKIT UMUM SARI MULIA BANJARMASIN

Tanggal September 2020

Disusun oleh :

MELLYSA
11194561920055

Banjarmasin, September 2020

Mengetahui,

Preseptor Akademik, (PA) Preseptor Klinik, (PK)

M. Riduansyah, S.Kep., Ns., M.Kep M. Agus Abdi, S.Kep., Ns

NIK. 1166072017105 NIK.
 LEMBAR PERSETUJUAN

RESUME KEPERAWATAN PADA NY. M DENGAN GASTRITIS

DI RUANG IGD RUMAH SAKIT UMUM SARI MULIA BANJARMASIN

Tanggal 25 September 2020

Disusun oleh :

MELLYSA
11194561920055

Banjarmasin, 25 September 2020

Mengetahui,

Preseptor Akademik, (PA) Preseptor Klinik, (PK)

M. Riduansyah, S.Kep., Ns., M.Kep M. Agus Abdi, S.Kep., Ns

NIK. 1166072017105 NIK.
 LEMBAR PERSETUJUAN

RESUME KEPERAWATAN PADA NY. Y DENGAN HIPERTENSI

DI RUANG IGD RUMAH SAKIT UMUM SARI MULIA BANJARMASIN

Tanggal September 2020

Disusun oleh :

MELLYSA
11194561920055

Banjarmasin, September 2020

Mengetahui,

Preseptor Akademik, (PA) Preseptor Klinik, (PK)

M. Riduansyah, S.Kep., Ns., M.Kep M. Agus Abdi, S.Kep., Ns

NIK. 1166072017105 NIK.
 FORMAT PENGKAJIAN
STASE KEPERAWATAN DASAR PROFESI

I. IDENTITAS KLIEN
Nama : …………………… Suku : …………………………
Tanggal lahir/Umur: …………………… Tgl masuk : …………………………
Jenis kelamin : …………………… Tgl dikaji : …………………………
Alamat : …………………… Ruang perawatan: …………………...
Pendidikan : …………………… Diagnosa medis :
……………………
Agama : …………………… No. Rekam Medis : ………………….

Identitas Penanggung jawab

Nama : …………………… Alamat : …………………………
Umur : …………………… Pendidikan : …………………………
Jenis kelamin : …………………… Pekerjaan : …………………………
Suku/bangsa : …………………… Hubungan : …………………………

PENGKAJIAN
a. Keluhan Utama:
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b. Riwayat Penyakit Dahulu:
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c. Riwayat Penyakit Sekarang:
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d. Riwayat Keluarga: Genogram:

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e. Keadaan umum :
f. Tingkat
kesadaran:
g. Antropometrik : TB : .................................. cm BMI: ..................................
BB : ..................T................
cm
h. TTV : RR ............ x/m SpO2 .................. %
HR ............ x/m Suhu .................. 0C
TD ............ mmHg MAP .................. mmHg
i. Kebutuhan O2 : Via:
j. Pemeriksaan fisik :
1. Kulit,
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Kuku
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2. Rambut
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, Kepala, Mata,
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Telinga
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3. Hidung, ......................................................................................................................
Mulut/ ......................................................................................................................
Tenggorokan ......................................................................................................................
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4. Leher, ......................................................................................................................
Thorax/dada, ......................................................................................................................
Abdomen ......................................................................................................................
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5. Ekstre ......................................................................................................................
mitas, ......................................................................................................................
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6. Genitali ......................................................................................................................
a, anus, ......................................................................................................................
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7. Refleks ......................................................................................................................
neurologis ......................................................................................................................
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8. Nervus ......................................................................................................................
Cranial ......................................................................................................................
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k. Kebutuhan Cairan :

l. Intake cairan : Output Cairan :

m. Balance Cairan :

n. Nutrisi : Sebelum di RS Sesudah di RS

Frekuensi : .............................. ................................................................
Porsi makan/minum: ................ ................................................................
Keterangan: .............................. ................................................................
o. Pola tidur : Sebelum di RS Sesudah di RS
Siang/ malam : .....jam/ ... jam Siang/ malam : .....jam/ .......jam
Kebiasaan tidur: ....................... Kebiasaan tidur: ........................

p. Kebersihan diri : Sebelum di RS Sesudah di RS

Mandi : ................ x/hari Mandi : ................ x/hari
Sikat gigi : ................ x/hari Sikat gigi : ................ x/hari
Potong kuku: ................ x/hari Potong kuku: ................ x/hari

q. Eliminasi : Sebelum di RS Sesudah di RS

BAB: ........ x/hari BAB: ........ x/hari
BAK: ........ x/hari BAK: ........ x/hari

r. Spiritualitas : Apa aktivitas spiritualitas Anda sebelum masuk RS?

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Selama di RS, apakah Anda masih bisa melakukan aktivitas spiritualitas?
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Jika, tidak. Apakah hal tersebut menjadi kekhawatiran Anda?
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s. ADL (Indeks Barthel)

Item penilaian Skor Hasil

Makan (Feeding) 0 = tidak mampu
1 = butuh bantuan
2 = mandiri
Mandi (Bathing) 0 = butuh bantuan
1 = mandiri
Perawatan diri (Grooming)
Berpakaian (Dressing)
Buang air kecil (Bowel)
Buang air besar (Bladder)
Penggunaan toilet
Transfer
Mobilitas
Naik turun tangga
Total Skor
0 = butuh bantuan
1 = mandiri
0 = butuh bantuan total
1 = sebagian dibantu
2 = mandiri
0 = inkontinensia/ pakai kateter
1 = kadang inkontinensia (1x/ minggu)
2 = kontinensia
0 = inkontinensia/ perlu enema
1 = kadang inkontinensia (1x/ minggu)
2 = kontinensia
0 = butuh bantuan total
1 = sebagian dibantu
2 = mandiri
0 = tidak mampu
1 = butuh bantuan (2 orang)
2 = butuh bantuan (1 orang)
3 = mandiri
0 = immobile
1 = menggunakan kursi roda
2 = berjalan dengan bantuan 1 orang
3 = mandiri
0 = tidak mampu
1 = butuh bantuan
2 = mandiri

Keterangan: Skor 20 : mandiri

Skor 12-19 : ketergantungan ringan
Skor 9-11 : ketergantungan sedang
Skor 5-8 : ketergantungan berat
Skor 0-4 : ketergantungan total

t. Nyeri :
Pengkajian nyeri pada anak (QUESTT) Pengkajian nyeri pada dewasa (PQRST)

Q  question the child (tanyakan pada anak) P  Provokatif / Paliatif

U  Use a pain rating scale (tanyakan pada anak) Q  Qualitas / Quantitas
E  Evaluate behavioral and physiologic changes R  Region / Radiasi
(evaluasi perubahan sikap dan fisiologis) S  Skala Nyeri
S  Secure parent’s involvement (pastikan T  Timing
keterlibatan orangtua)
T  Take the cause of pain into account
(pertimbangkan penyebab nyeri)
T  Take action and evaluate results (lakukan
tindakan dan evaluasi hasilnya)
 Pengkajian Skala Nyeri dengan FLACC (usia < 3 tahun)
SKOR
NO KATEGORI TOTAL
0 1 2
Face (Wajah) Tidak ada Menyeringai, Dagu gemetar,
ekspresi khusus, mengerutkan gigi gemeretak
senyum dahi, tampak (sering)
tidak tertarik
(kadang-
kadang)
2 Leg (Kaki) Normal, rileks Gelisah, tegang Menendang,
kaki tertekuk
3 Activity (Aktivitas) Berbaring Menggeliat, Kaku atau
tenang, posisi tidak bisa diam, kejang
normal, gerakan tegang
mudah
4 Cry (Menangis) Tidak menangis Merintih, Terus menangis,
merengek, berteriak, sering
kadang-kadang mengeluh
mengeluh
5 Consability Rileks Dapat Sulit dibujuk
(Konsabilitas) ditenangkan
dengan
sentuhan,
pelukan,
bujukan, dapat
dialihkan
SKOR TOTAL
Keterangan:
Skor 1 – 3 = nyeri ringan Skor 4 – 6 = nyeri sedang Skor 7 – 10 = nyeri berat

Pengkajian Skala Nyeri dengan Wong-Baker FACES Pain Rating Scale (3-7 tahun)

Wajah 0 : sangat senang karena tidak ada rasa sakit sama sekali.
Wajah 1 : rasa sakit hanya sedikit.
Wajah 2 : rasa sakit sedikit lebih (agak sakit).
Wajah 3 : rasa sakit agak lebih (sakit sekali).
Wajah 4 : rasa sakit yang dalam (sangat sakit sekali).
Wajah 5 : rasa sakit yang hebat (sangat kesakitan/ nyeri hebat) meskipun anak tidak
harus menangis karena merasa ini buruk.

Pengkajian Skala Nyeri dengan Visual Analog Scale (VAS) (> usia 7 tahun/ dewasa)
u. Resiko Jatuh :
MORSE FALL SCALE (MFS)/ SKALA JATUH DARI MORSE

No. PENGKAJIAN SKALA NILAI KET.

Riwayat jatuh: Tidak 0
1. Apakah pasien pernah jatuh dalam 3 bulan
Ya 25
terakhir?
Diagnosa sekunder: Tidak 0
2. Apakah pasien memiliki lebih dari satu
Ya 25
penyakit?
3. Alat bantu jalan:
0
 Bed rest/dibantu perawat?
 Kruk/tongkat/walker 15
 Berpegangan pada benda-benda disekitar
30
(kursi, lemari, meja)
Terapi Intravena: Tidak 0
4.
Apakah pasien saat ini terpasang infus? Ya 20
Gaya berjalan/cara berpindah:
5.  Normal/bed rest/ immobile (tidak dapat 0
bergerak sendiri)
 Lemah (tidak bertenaga) 10
 Gangguan/ tidak normal (pincang/diseret) 20
Status Mental:
6. 0
 Pasien menyadari kondisi dirinya
 Pasien mengalami keterbatasan daya ingat 15
TOTAL
Nilai 0-24 : tidak beresiko
Nilai 25-50 : risiko rendah
Nilai > 51 : risiko tinggi

SKALA RESIKO JATUH ONTARIO MODIFIED STRTIFY – SYDNEY SCORING

UNTUK GERIATRI
Keterangan
No. Parameter Skrining Jawaban Skor
Nilai
1. Riwayat Jatuh Apakah pasien datang kerumah sakit karena Salah satu
Ya/Tidak
jatuh? jawaban Ya=6
Jika tidak, apakah pasien mengalami jatuh
Ya/Tidak
dalam 2 bulan terakhir ini?
2. Status Mental Apakah pasien delirium? (tidak dapat Salah satu
membuat keputusan, pola pikir tidak Ya/Tidak jawaban
terorganisir, gangguan daya ingat) Ya=14
Apakah pasien disorientasi? (salah
Ya/Tidak
menyebutkan waktu, tempat atau orang)
Apakah pasien mengalami agitasi? (ketakutan,
Ya/Tidak
gelisah, dan cemas)
3. Penglihatan Apakah pasien memakai kacamata? Ya/Tidak Salah satu
Apakah pasien mengeluh adanya penglihatan jawaban Ya=1
Ya/Tidak
buram?
Apakah pasien mempunyai
Ya/Tidak
Glaukoma/Katarak/ Degenerasi Makula?
Kebiasaan Apakah terdapat perubahan perilaku
4. berkemih berkemih? (frekuensi, urgensi, inkontinensia, Ya/Tidak Ya=2
nokturia)
5. Transfer (dari Mandiri (boleh memakai alat bantu jalan) 0 Jumlah nilai
 tempat tidur ke Memerlukan sedikit bantuan (1 orang) /dalam
1 transfer dan
kursi dan pegawasan
kembali lagi ke Memerlukan bantuan yang nyata (2 orang) 2 mobilitas.
tempat tidur) Jika nilai total
Tidak dapat duduk dengan seimbang, perlu
3 0 – 3 maka
bantuan total
skor = 0
6 Mobilitas Mandiri (boleh menggunakan alat bantu jalan) 0
Jika nilai total
Berjalan dengan bantuan 1 orang (verbal/fisik) 1
4 – 6, maka
Menggunakan kursi roda 2 skor = 7
Immobilisasi 3
TOTAL
Keterangan skor:
0 – 5: resiko rendah 6 – 16 : resiko sedang 17 – 30 : resiko tinggi

SKALA RESIKO JATUH UNTUK ANAK

Parameter Kriteria Nilai Skor
< 3 tahun 4
3 – 7 tahun 3
Umur
7 – 13 tahun 2
≥ 13 tahun 1
Laki-laki 2
Jenis Kelamin
Perempuan 1
Kelainan neurologi 4
SKRINING RISIKO JATUH (Humpthy Dumpty)

Perubahan dalam oksigenasi (masalah sal. Nafas, anemia, 3

Diagnosis dehidrasi, anoreksia, sakit kepala, sinkop/pusing, dll)
Kelainan psikis/ perilaku 2
Diagnosis lain 1
Tidak menyadari keterbatasan 3
Gangguan
Lupa akan keterbatasan diri 2
Kognitif
Sadar akan kemampuan sendiri 1
Riwayat jatuh dari tempat tidur saat bayi – anak 4
Pasien menggunakan alat bantu atau tempat tidur bayi/ 3
Faktor
pencahayaan
Lingkungan
Pasien berada di tempat tidur 2
Rawat Jalan 1
Respon terhadap Dalam 24 jam 3
operasi/ obat Dalam 48 jam 2
penenang/ efek >48 jam/ tidak ada 1
anastesi
Bermacam-macam obat digunakan: obat sedative (diluar 3
pasien ICU yang sedang mengalami sedasi dan paralisis),
hipnotik, barbiturate, fenotiazin, antidepresan, laksatif,
Penggunaan obat
diuretic, narkotik
Salah satu dari pengobatan diatas 2
Pengobatan lain/tidak ada 1
Skor 7 – 11 : Risiko rendah untuk
jatuh Skor Minimal : 7
TOTAL
Skor ≥ 12 : Risiko tinggi untuk Skor Maksimal : 23
jatuh
v. Skala Cemas (Hamilton Rating Scale for Anxiety/ HARS) :

Skor
No Pertanyaan
0 1 2 3 4
1 Perasaan Ansietas
- Cemas
- Firasat Buruk
- Takut Akan Pikiran Sendiri
- Mudah Tersinggung
2 Ketegangan
- Merasa Tegang
- Lesu
- Tak Bisa Istirahat Tenang
- Mudah Terkejut
- Mudah Menangis
- Gemetar
- Gelisah
3 Ketakutan
- Pada Gelap
- Pada Orang Asing
- Ditinggal Sendiri
- Pada Binatang Besar
- Pada Keramaian Lalu Lintas
- Pada Kerumunan Orang Banyak
4 Gangguan Tidur
- Sukar Masuk Tidur
- Terbangun Malam Hari
- Tidak Nyenyak
- Bangun dengan Lesu
- Banyak Mimpi-Mimpi
- Mimpi Buruk
- Mimpi Menakutkan
5 Gangguan Kecerdasan
- Sukar Konsentrasi
- Daya Ingat Buruk
6 Perasaan Depresi
- Hilangnya Minat
- Berkurangnya Kesenangan Pada Hobi
- Sedih
- Bangun Dini Hari
- Perasaan Berubah-Ubah Sepanjang Hari
7 Gejala Somatik (Otot)
- Sakit dan Nyeri di Otot-Otot
- Kaku
- Kedutan Otot
- Gigi Gemerutuk
- Suara Tidak Stabil
8 Gejala Somatik (Sensorik)
- Tinitus
- Penglihatan Kabur
- Muka Merah atau Pucat
- Merasa Lemah
- Perasaan ditusuk-Tusuk
9 Gejala Kardiovaskuler
- Takhikardia
- Berdebar
- Nyeri di Dada
- Denyut Nadi Mengeras
- Perasaan Lesu/Lemas Seperti Mau Pingsan
- Detak Jantung Menghilang (Berhenti
Sekejap)
10 Gejala Respiratori
- Rasa Tertekan atau Sempit Di Dada
- Perasaan Tercekik
- Sering Menarik Napas
- Napas Pendek/Sesak
11 Gejala Gastrointestinal
- Sulit Menelan
 - Perut Melilit
- Gangguan Pencernaan
- Nyeri Sebelum dan Sesudah Makan
- Perasaan Terbakar di Perut
- Rasa Penuh atau Kembung
- Mual
- Muntah
- Buang Air Besar Lembek
- Kehilangan Berat Badan
- Sukar Buang Air Besar (Konstipasi)
12 Gejala Urogenital
- Sering Buang Air Kecil
- Tidak Dapat Menahan Air Seni
- Amenorrhoe
- Menorrhagia
- Menjadi Dingin (Frigid)
- Ejakulasi Praecocks
- Ereksi Hilang
- Impotensi
13 Gejala Otonom
- Mulut Kering
- Muka Merah
- Mudah Berkeringat
- Pusing, Sakit Kepala
- Bulu-Bulu Berdiri
14 Tingkah Laku Pada Wawancara
- Gelisah
- Tidak Tenang
- Jari Gemetar
- Kerut Kening
- Muka Tegang
- Tonus Otot Meningkat
- Napas Pendek dan Cepat
- Muka Merah
Total Skor

Keterangan:
Skor: 0 = tidak ada Total Skor:
1 = ringan kurang dari 14 = tidak ada kecemasan
2 = sedang 14 – 20 = kecemasan ringan
3 = berat 21 – 27 = kecemasan sedang
4 = berat sekali 28 – 41 = kecemasan berat
42 – 56 = kecemasan berat sekali
w. Hasil laboratorium
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x. Foto thoraks, dll (Hasil pembacaan)

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y. Terapi Farmakologi
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Analisis Data
DATA KLIEN MASALAH
No ETIOLOGI
(Data Subjektif & Data Objektif) KEPERAWATAN

Diagnosa Keperawatan
1. ..............................................................................................................................
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2. ..............................................................................................................................
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3. ..............................................................................................................................
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4. ..............................................................................................................................
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 5. ..............................................................................................................................
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Rencana Keperawatan
Diagnosa Perencanaan
No
Keperawatan Tujuan Keperawatan & NOC Intervensi Keperawatan (NIC)

Implementasi dan Evaluasi

Nomor Dx Implementasi Evaluasi

Hari/ Tgl Jam TTD
Keperawatan Keperawatan Keperawatan

S:
 O:

A:

P:

Catatan Perkembangan

Nomor Dx Implementasi Evaluasi

Hari/ Tgl Jam TTD
Keperawatan Keperawatan Keperawatan

S:
 O:

A:

P:

FORMAT RESUME
STASE KEPERAWATAN DASAR PROFESI
I. IDENTITAS KLIEN
Nama : …………………… Suku : …………………………
Tanggal lahir/Umur: …………………… Tgl masuk : …………………………
Jenis kelamin : …………………… Tgl dikaji : …………………………
Alamat : …………………… Ruang perawatan: …………………...
 Pendidikan : …………………… Diagnosa medis :
……………………
Agama : …………………… No. Rekam Medis : ………………….

Identitas Penanggung jawab

Nama : …………………… Alamat : …………………………
Umur : …………………… Pendidikan : …………………………
Jenis kelamin : …………………… Pekerjaan : …………………………
Suku/bangsa : …………………… Hubungan : …………………………

II. PENGKAJIAN
a. Keluhan Utama:
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b. Riwayat Penyakit Dahulu:
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c. Riwayat Penyakit Sekarang:
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d. Riwayat Keluarga: Genogram:

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III. DATA FOKUS

A. Data Subjektif
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B. Data Objektif
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C. Hasil Lab/ dll

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IV. Analisis Data

DATA KLIEN MASALAH

No ETIOLOGI
(Data Subjektif & Data Objektif) KEPERAWATAN
V. Diagnosa Keperawatan
1. ..............................................................................................................................
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2. ..............................................................................................................................
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3. ..............................................................................................................................
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4. ..............................................................................................................................
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5. ..............................................................................................................................
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Rencana Keperawatan
Diagnosa Perencanaan
No
Keperawatan Tujuan Keperawatan & NOC Intervensi Keperawatan (NIC)
Implementasi dan Evaluasi
Nomor Dx Implementasi Evaluasi
Hari/ Tgl Jam TTD
Keperawatan Keperawatan Keperawatan

S:

O:

A:

P:
 FORMAT RESUME
STASE KEPERAWATAN DASAR PROFESI
 I. IDENTITAS KLIEN
Nama : …………………… Suku : …………………………
Tanggal lahir/Umur: …………………… Tgl masuk : …………………………
Jenis kelamin : …………………… Tgl dikaji : …………………………
Alamat : …………………… Ruang perawatan: …………………...
Pendidikan : …………………… Diagnosa medis :
……………………
Agama : …………………… No. Rekam Medis : ………………….

Identitas Penanggung jawab

Nama : …………………… Alamat : …………………………
Umur : …………………… Pendidikan : …………………………
Jenis kelamin : …………………… Pekerjaan : …………………………
Suku/bangsa : …………………… Hubungan : …………………………

II. PENGKAJIAN
a. Keluhan Utama:
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
b. Riwayat Penyakit Dahulu:
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
c. Riwayat Penyakit Sekarang:
.............................................................................................................................................................
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.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
 .............................................................................................................................................................

d. Riwayat Keluarga: Genogram:

.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................

II. DATA FOKUS

A. Data Subjektif
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B. Data Objektif
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C. Hasil Lab/ dll

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..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

III. Analisis Data

DATA KLIEN MASALAH

No ETIOLOGI
(Data Subjektif & Data Objektif) KEPERAWATAN
IV. Diagnosa Keperawatan
1. ..............................................................................................................................
...........
2. ..............................................................................................................................
...........
3. ..............................................................................................................................
...........
4. ..............................................................................................................................
...........
5. ..............................................................................................................................
............

Rencana Keperawatan
Diagnosa Perencanaan
No
Keperawatan Tujuan Keperawatan & NOC Intervensi Keperawatan (NIC)
Implementasi dan Evaluasi
Nomor Dx Implementasi Evaluasi
Hari/ Tgl Jam TTD
Keperawatan Keperawatan Keperawatan

S:

O:

A:
P: