Program Studi Pendidikan Profesi Ners STIKES Guna Bangsa Yogyakarta

FORMAT LAPORAN
RESUME KEPERAWATAN DASAR PROFESI

1. PENGKAJIAN
A. IDENTITAS KLIEN
Nama (Inisial) :
L/P :
Umur :
Alamat :
Pendidikan :
Agama :
No. RM :
Tgl Pengkajian :

B. ALASAN MASUK
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C. KELUHAN UTAMA
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D. PEMERIKSAAN FISIK
Keadaan umum :
TD :
Nadi :
Respirasi :
Suhu :
E. DATA FOKUS
DATA SUBYEKTIF DATA OBYEKTIF

F.ANALISA DATA

No DATA ETIOLOGI PROBLEM

1. Subyektif
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Program Studi Pendidikan Profesi Ners STIKES Guna Bangsa Yogyakarta

Obyektif
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2. Subyektif
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Obyektif
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G. DAFTAR DIAGNOSA KEPERAWATAN (PRIORITAS)

1. ............................................................................................................................
2. ............................................................................................................................

H. RENCANA INTERVENSI KEPERAWATAN

NO DIAGNOSA NOC NIC

TGL/JAM KEPERAWATAN

I. IMPLEMENTASI DAN EVALUASI

NO IMPLEMENTASI EVALUASI FORMATIF EVALUASI

TGL/JAM SUMATIF