KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KALIMANTAN TIMUR

Direktorat Jalan Kurnia MakmurNo. 64 Rt. 24 Kel. Harapan Baru Kecamatan Loa Janan Ilir No. Telp (0541) 7091774
Jurusan Keperawatan, Jurusan Kebidanan, Jurusan Analis Kesehatan
Jalan Wolter Monginsidi No. 38 Samarinda – Kalimantan Timur, Kode Pos 75123, Telepon (0541) 738153, 768522 Fax : (0541)768523
Program Studi Diploma III Kebidanan Balikpapan, Jalan Sorong No. 9 RT.081 Gunung Pipa Balikpapan Utara Telepon : (0542) 424704 Fax : (0542) 415551
Surat Elektronik : poltekkes_smd2007@yahoo.co.id Laman : http://poltekkes-kaltim.ac.id

RESUME ASUHAN KEPERAWATAN

STASE KEPERAWATAN ANAK
NAMA PRESEPTEE : .........................................................
NIM : ..................................................….....
TINGKAT/SEMESTER/JALUR : ................................................….......
RUMAH SAKIT/RUANG : ................................................…,......
HARI / TANGGAL : ..................................................….....

A. Data Umum

A. Biodata Klien :
Nama Pasien (Inisial) : ...........................................................................................….........
Jenis Kelamin :
.......................................................................................................... Status Perkawinan :
.......................................................................................................... Agama :
.......................................................................................................... Pendidikan Terakhir :
.......................................................................................................... Pekerjaan :
.......................................................................................................... Suku :
.......................................................................................................... Alamat :
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Tanggal Masuk RS : ..........................................................................................................
Tanggal Pengkajian : ..........................................................................................................
Dx. Medis : ..........................................................................................................
No. Register :
B. ..........................................................................................................

Biodata Penanggungjawab :
Nama Pasien (Inisial) : ..........................................................................................................
Jenis Kelamin : ..........................................................................................................
Status Perkawinan : ..........................................................................................................
Agama : ..........................................................................................................
Pendidikan Terakhir : ..........................................................................................................
Pekerjaan : ..........................................................................................................
Suku : ..........................................................................................................
Alamat : ..........................................................................................................
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A. Riwayat Kesehatan
1. Keluhan Utama :
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2. Riwayat Penyakit Sekarang :

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 3. Riwayat Penyakit Dahulu :
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4. Riwayat Penyakit Dalam Keluarga : (Genogram)

PEMERIKSAAAN FISIK

1. Keadaan Umum
Posisi pasien :
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Alat medis/ invasif yang terpasang :
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Tanda klinis yang mencolok : ( ) sianosis ( ) perdarahan
Sakit ringan Sakit sedang Sakit berat

2. Kesadaran :
Kualitatif :
Compos Mentis Apatis Somnolen Sopor Koma

Kuantitatif : GCS : E…….. .M…….. V..........

a. Tanda – tanda vital

TD : …….…… mmHg N : ………x / menit R : ……… x / menit S : ….. ◦C
( )
MAP : =................... mmHg (N : 70-90 mmHg)

b. Berat Badan (Antopometri)

Sebelum MRS : ………… Kg, Sekarang : ………… Kg
Tinggi badan : …………. Cm

Hasil Pemeriksaan Penunjang :

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Pemeriksaan Laboratorium :
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Jurusan Keperawatan, Jurusan Kebidanan: Jalan Wolter Monginsidi No. 38 Samarinda – Kalimantan Timur, Kode Pos 75123, Telepon (0541) 738153
Jurusan Analis Kesehatan : Jalan Kurnia Makmur No. 64 Rt. 24 Kel. Harapan Baru Kec. Loa Janan Ilir
Program Studi Diploma III Kebidanan Balikpapan, Jalan Sorong No. 9 RT.081 Gunung Pipa Balikpapan Utara Telepon : (0542) 424704 Fax : (0542)
415551
 C. Pengkajian Data Fokus

5. Kondisi Pasien :
DS : ………………………………………………………………………………………..
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DO : ………………………………………………………………………….……………..
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6. Diagnosa Keperawatan :
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7. Tujuan Khusus (Alasan dilakukan tindakan) :

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Jurusan Keperawatan, Jurusan Kebidanan: Jalan Wolter Monginsidi No. 38 Samarinda – Kalimantan Timur, Kode Pos 75123, Telepon (0541) 738153
Jurusan Analis Kesehatan : Jalan Kurnia Makmur No. 64 Rt. 24 Kel. Harapan Baru Kec. Loa Janan Ilir
Program Studi Diploma III Kebidanan Balikpapan, Jalan Sorong No. 9 RT.081 Gunung Pipa Balikpapan Utara Telepon : (0542) 424704 Fax : (0542)
415551
 KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
BADAN PENGEMBANGAN DAN PEMBERDAYAAN
SUMBER DAYA MANUSIA KESEHATAN
POLITEKNIK KESEHATAN KALIMANTAN TIMUR
Jalan Kurnia Makmur No. 64 RT. 24 Kelurahan Harapan Baru Kecamatan Loa Janan Ilir
Samarinda Kalimantan Timur Telp (0541)738153, Faksimile (0541)768523
Laman:http// www.poltekkes-kaltim.ac.id Surat Elektronik: poltekkes_smd2007@yahoo.co.id

ASUHAN KEPERAWATAN
NO. DIAGNOSA TUJUAN / IMPLEMENTASI
INTERVENSI EVALUASI
KEPERAWATAN KRITERIA HASIL JAM TINDAKAN

Jurusan Keperawatan, Jurusan Kebidanan: Jalan Wolter Monginsidi No. 38 Samarinda – Kalimantan Timur, Kode Pos 75123, Telepon (0541) 738153
Jurusan Analis Kesehatan : Jalan Kurnia Makmur No. 64 Rt. 24 Kel. Harapan Baru Kec. Loa Janan Ilir
Program Studi Diploma III Kebidanan Balikpapan, Jalan Sorong No. 9 RT.081 Gunung Pipa Balikpapan Utara Telepon : (0542) 424704 Fax : (0542)
415551