RESUME

STASE KEPERAWATAN DASAR PROFESI

I. IDENTITAS KLIEN
Nama : Tn. H Suku : Banjar
Tanggal lahir/Umur : 54 tahun Tgl masuk : 27 September 2020
Jenis kelamin : Laki-laki Tgl dikaji : 28 September 2020
Alamat : Banjarmasin Ruang perawatan: Tulip 3B
Pendidikan : SMP Diagnosa medis : Melena
Agama : Islam No. Rekam Medis : xx.yy

Identitas Penanggung jawab

Nama : Ny. I Alamat : Banjarmasin
Umur : 40 tahun Pendidikan : SD
Jenis kelamin : Perempuan Pekerjaan : Swasta
Suku/bangsa : Banjar Hubungan : Istri Pasien

II. PENGKAJIAN
a. Keluhan Utama:
Pasien mengeluh sesak

b. Riwayat Penyakit Dahulu:

Menurut keluarga pasien sebelumnya tidak pernah mempunyai penyakit berat seperti Asma,
Jantung, Hipertensi

c. Riwayat Penyakit Sekarang:

Sebelumnya Pasien mengeluh sering merasa lelah, perut sakit, dan BAB berdarah, lalu pasien
dibawa ke rumah sakit untuk dilakukan pengobatan.

d. Riwayat Keluarga: Genogram:

Keluarga tidak memiliki riwayat Asma,
Jantung ataupun Hipertensi

x x x x

Keterangan:

: Pasien

: Laki-Laki

: Perempuan

: Tinggal Serumah
III. DATA FOKUS
 A. Data Subjektif
Pasien mengeluh sesak, Lemas dan Pusing

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

S:

O:

A:

P: