KEMENTERIAN KESEHATAN R.

I
POLITEKNIK KESEHATAN JAMBI
JURUSAN KEPERAWATAN
JL.DR. TAZAR KELURAHAN BULURAN KENALI KEC. TELANAIPURA JAMBI

RESUME PRAKTIK KLINIK KEPERAWATAN MEDIKAL BEDAH II

TEMPAT PRAKTIK :............................................................................

NAMA KLIEN : ............................................................................
NO REGISTER : ............................................................................
UMUR : ............................................................................
JENIS KELAMIN : ............................................................................
DIAGNOSA MEDIS : ............................................................................

KELUHAN UTAMA :

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HASIL PEMERIKSAAN FISIK (INSPEKSI, PALPASI, PERKUSI , AUSKULTASI) :

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HASIL PEMERIKSAAN PENUNJANG

(RADIOGRAFI, HEMATOLOGI, KIMIA DARAH, CT SCAN, MRI, USG, EKG,
DLL):

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TERAPI MEDIS:

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TINDAKAN (KEPERAWATAN DAN MEDIS):

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EVALUASI

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 ANALISIS DATA

NO. DATA PENYEBAB MASALAH

 DIAGNOSIS KEPERAWATAN

NO. TGL/ JAM DIAGNOSIS KEPERAWATAN PARAF

 RENCANA KEPERAWATAN

TGL/ JAM DIAGNOSA

TUJUAN RENCANA TINDAKAN RASIONALISASI PARAF
KEPERAWATAN
 PELAKSANAAN TINDAKAN KEPERAWATAN

NO. DK TGL/ JAM TINDAKAN KEPERAWATAN PARAF

 EVALUASI

MASALAH TGL/
CATATAN PERKEMBANGAN PARAF
KEPERAWATAN JAM