LAPORAN RESUME

ASUHAN KEPERAWATAN PADA TN/NY/Sdr.................

DENGAN DIAGNOSA MEDIS...............................................
RS PKU MUHAMMADIYAH GAMPING
SLEMAN

Disusun oleh:

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

PROGRAM STUDI PROFESI NERS

FAKULTAS ILMU KESEHATAN

UNIVERSITAS ‘AISYIYAH

YOGYAKARTA

2020
 ASUHAN KEPERAWATAN PADA TN/NY/Sdr.................
DENGAN DIAGNOSA MEDIS...............................................
RS PKU MUHAMMADIYAH GAMPING
SLEMAN

I. DATA DEMOGRAFI

1. Nama :.........................................................

2. Tanggal lahir :.........................................................

3. Jenis :.........................................................

4. Kelamin :.........................................................

5. Alamat :.........................................................

6. No.RM :.........................................................

7. Tanggal Masuk RS:.........................................................

8. Tanggal Pengkajian:........................................................

II. KELUHAN UTAMA

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

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

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

III. TREAGE PRIMER: (Emergency Severity Index)

: ESI Level 1

: ESI Level 2

: ESI Level 3

: ESI Level 4

: ESI Level 5
IV. SURVEI PRIMER

1. Airway

a. Look :.............................................................................................................

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

b. Listen :.............................................................................................................

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

c. Feel :.............................................................................................................

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

d. Servical :..............................................................................................................

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

e. Kondisi jalan napas

: Paten
: Obstruksi
: Stridor
: Gurgling
: Shoring
2. Breathing

a. Look :.............................................................................................................

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

b. Listen :.............................................................................................................

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

c. Feel :.............................................................................................................

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

d. Kondisi pernapasan

: Spontan
: Apnea
: Sianosis
:
:
:
e. Ekspansi dada :...................................................................................................
 f. Auskultasi :....................................................................................................

g. Saturasi oksigen :....................................................................................................

3. Circulation

a. Look :.............................................................................................................

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

b. Listen :.............................................................................................................

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

c. Feel :.............................................................................................................

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

d. Nadi :................................................................................................................

e. Kulit :................................................................................................................

f. CRT :.................................................................................................................

4. Disability

1. GCS : E ........................... V..................... M ........................................

2. Pupil :........................................................................................................

3. Reflek cahaya :........................................................................................................

4. AEIOU

A : .....................................................................................................................

E :......................................................................................................................

:......................................................................................................................
I
:......................................................................................................................
O
:......................................................................................................................
U
5. Exposure

: Dalam batas normal

: Luka
 : Deformitas

: Perdarahan

: Nyeri tekan

: Pembengkakan

Tanda-tanda vital: TD ................ N ............. S .............. R .............

Nyeri:
P :...............................................................................................................

Q :...............................................................................................................

R :...............................................................................................................

S :................................................................................................................

T :...............................................................................................................

V. SURVEI SEKUNDER

1. Keluhan utama :....................................................................................................

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

2. Riwayat penyakit sekarang :..................................................................................

3. AMPLE :...............................................................................................................

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

4. Pemeriksaan Fisik

a. Kepala :....................................................................................................

b. Leher :....................................................................................................

c. Thorak :...................................................................................................

d. Abdomen :...................................................................................................

e. Pelvis :...................................................................................................

f. Ekstremitas :...................................................................................................

g. BB ................ TB .................
VI. TES DIAGNOSTIK
VII. TERAPI SAAT INI

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

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

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

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

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

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

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

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

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

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

.................................................................................................................................
VIII. ANALISA DATA

No Data Masalah Etiologi

 Prioritas Masalah Keperawatan:

1. .......................................................................................................................

2. .......................................................................................................................

3. .......................................................................................................................

4.

IX. RENCANA INTERVENSI KEPERAWATAN

No Diagnosa Tujuan Intervensi

Keperawatan NOC NIC

No Diagnosa Tujuan Intervensi

Keperawatan NOC NIC

 X. IMLEMENTASI KEPERAWATAN

No Diagnosa Imlementasi Evaluasi

Keperawatan Keperawatan SOAP

No Diagnosa Imlementasi Evaluasi

Keperawatan Keperawatan SOAP