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RESUME RUANG OK

Di Rumah Sakit...............................................................................

Laporan kasus pada ..........dengan diagnosa medik ...............................................

Tanggal pengkajian     : ………………….


Tanggal Operasi          : …………………
Tempat Praktek           : Ruangan OK RS………..

1.      Post operasi care


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a.       Identitas
Nama pasien          : ................
Jenis kelamin         : ................
Usia                       : ................
Status perkwinan  : ................
Agama                   : ................
Suku                      : ................
Pekerjaan               : ................
Alamat                  : ................
Diagnosa medik    : ................

2.      Keluhan utama


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3.      Riwayat penyakit
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4.      Pemeriksaan fisik
Keadaan umum           : ...........
Tingkat kesadaran       : ...........
GCS                            : E ...........
                                      V ...........
                                      M ...........
Nilai normal GCS       : ...........
Vital Sign                    : Tekanan darah : ...........
                                     Nadi               : ...........
                                     Suhu               : ...........
                                     Pernafasan      : ...........

Inspeksi                       : ...........


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-       ...................................................................................

Palpasi                          : ............................................................


Klien dipindahkan keruangan RR pukul ...................dengan kesadaran ........., klien terpasang
..................................... Hasil TTV yaitu :
a.       TTV (Post operasi) jam......
Tekanan darah       : ......
Nadi                      : ......
Suhu                      : ......
Pernafasan             : ......
b.      TTV (Post operasi) jam......
Tekanan darah       : ......
Suhu                      : ......
Nadi                      : ......
Pernafasan             : ......
c.       Instruksi dokter
Bedrest                  : ......
Diit                        : ......
d.      Terapi medis
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Analisa data
No Data Etiologi Problem
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