KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

DIREKTORAT JENDERAL TENAGA 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
RESUME ASUHAN KEPERAWATAN
STASE KEPERAWATAN DASAR PROFESI (KDP

NAMA PRESEPTEE Lfatia Toto

*****no*************** sesen***essssesss****
NIM
TINGKAT/SEMESTER/JALUR
RUMAH SAKIT/RUANNG .Arioo Wohaburar
HARI/TANGGAL . Salasa ulu J0

A. Data Umum

Biodata Klien:
Nama Pasien (Inisial) My M ***************** **********
Jenis Kelamin araupuCn **** ******

Status Perkawinan Sauwtn *a***v*********.**es***

Agama Prota itcn

MA **** ******* ******* ****

Pendidikan Terakhir *********a*e sseas****

Pekerjaan
Suku dyak

Alamat

Tanggal Masuk RS C/+(1022 1am u. a******

Tanggal Pengkajian :9a02Jum.Lo0o *************"***** *

Dx. Medis .Pon Chatt tube, Qfuh Paua
*******s
No. Register O93204 erossreoaosese*******

B. Biodata Penanggungjawab:
Nama Pasien (Inisial)
Jenis Kelamin Parampucn
Status Perkawinan Fawin
Agama .rotaston
*********
Pendidikan Terakhir
Pekerjaan
Suku Dagak «******* **aa *********

Alamat

*****

******* asnes

************************

B. Proses Keperawatan

A. Riwayat Kesehatan
1. Keluhan Utama
Saue************************************************g********
ncapcy ola aukttfttas **************************************
Sudah dtvukwn t 1baan
************************* **********a***** wess*** ********** **********s***

2. Riwayat Penyakit Sekarang:

Manga uh Sasa fapu lon tarpasang a 6 .P TUgu
mangauh batukarda hos numun.uit unful daluarkomdtlaktn
c Nabu vuntoltn cc mangqunakon dat nahu dain fudolh hta
manaauactan dohalet e t glaln tu ebraA. Manggtuh
RCidc
don dudut Dung9ungilcalcngGO2.K:Naarai
nLW Sdpart tartuut tuhuk
aat arquat
S T : taraiA fang m anqus.tatah dban konAut SauDna kanun
analgah
Haum bar an
Furang-D Tug unggLuh turgg
olan uaDd

Jurusan
Keperawatan, Jurusan Kebldanan: lalan Waler Monginsidi No. 38 Samarinda Kalimantan Timur, Kode Pos 75123, Telepon (0541)
-

738153
o o N O 0 . 4 KeL Harapdn Baru Kec. Loa Janan Ilr
Program Studi Diploma II Kebldanan Balkpapan, Jakan Sorang No. 9 RT.081 Gunung Pipa Balkpapan Utara Telepon : (0542) 424704 Fax: (0542) 415551
 3. Riwayat Penyakit Dahuju:
T) ngatafah ttdat atnah anexu (ca catalakaon
Dangopuan . Maag tumor
... . pani
un
e
S
a****
** *****************
******************************
******************************************************************************************************************************************************* ************

*************************************************************** **** * *********************

******
aemoomeroeeotwanana a*rwroeenaun ****w ********************************************************************* ********

*************************************************************************************************** ** **
* n nw a*o unnnanu* *cusosamann ammm********************************* **********************************

*************************"**************************************
www.u nn wa *********************************************************************************************

4. Riwayat Penyakit Dalam Keluarga: (Genogram)

Crda ada
Eaturangan
akH-lo
O'paraupun
Manin9pol
pa fvan

PEMERIKSAAAN FISIK

1. Keadaan Umum

*****
r Cea Ve Me). Penan tlrah banng dikauupct ttdur
*a* o*sansererntsas dsassasseanawasasssnaaesaseueosan****************************************************************************
Alat medis/ invas n, Oa***
6Lpm (Vf0Jo tp .
*******************************************************************
* * * * * * * * * * * * * * *

*** ****************** *************************************************************""*******"****"

Tanda klinis yang mencolok:( J sianosis perdarahan
Sakit ringan Sakit sedang Sakit berat
2. Kesadaran:
Kualitatif
Eompos Mentis Apatis Somnolen Sopor Koma
Kuantitatif: GCS: E. M....

a. Tanda-tanda vital
TD HDtoa.
mmHg N: 4..x/ menit R: x/menit S? C
Tekanan ststolik+(2 xtekanan diastolik)
MAP ***** ********* (N: 70-90 mmHg)
b. Berat Badan (Antopometri)
Sebelum MRS
Tinggi badan
K g , Sekarang
: A . Cm
2Kg
Hasiemerisnc Otasto tte 4rsfunqHo
..******************************** ********* ********* ************************************************************************************************

anusnnsns*sn *a* *** *******************

****** ***"*******************************************************************************************

***** ******"** *****"*** * * * * * * * * * * * * * * * * * * * * * *

** *****

**********

*****
************
**** ******************************

*******"********* **
** *******************************'"* *'"**""** *****"****""* ****"***********************************

******
*****

Pemeriksaan Laboratorium: :(lb

*******.*****.*"
aom.
*************
t .************
*************
.. s@o.:0. **********'*******'*************"**********

Ctrntro nt. ******************

********

dHausaloet *********************. *********

******************** ******

Nauto KLt..L...... eno******* ********************************* ***

.... N.2...
******************
***sestenss*4 ***essa**n**************"*"**********
*****

9 Albuuun 39
h. uraum N 14,0-4s ug (<L
Jurusan Keperawatan, Jurusan Kebldanan: abn Wotsr Monginsidl No. 38 SamarndaamantanTmur,Kode Pos75123, Tekpon (0541) 736153
r No. 64 Rt. 24 Ked. Harapan Baru Kec. Loa Janan lr
Program Studi Diploma II Kebldanan Baikpapan, Jolbn SorongNo. 9 RT.081 SunungPips Bakpapanutaraelepon: (US42) 424704 Fax : (u542) 415551
 C. Pengkajian Data Fokus

5.
KondisPaslen'onanmatatan Jajak Socut barukt{tts
PaangngekdkcätiGkaekfavajo Suat bargara
Hän duzu a*NYiän ku prut tartutuEu panut Saupi nqleunan * " * * * * *

aia taus mdnana.

nan.maagatukn *****""******is
ck..untukbar4.do 41bantu o lan **"*************

DO 0..0. 64. Onm..2R2Pa(m

**i*****************

"*******"******"****

Vuntoiin3c***
Dasang ngbu ************** **""**********************************

**************** **************************** *****

Dx Fanogio...
x9dfah **************"*********************************

ndoKS bEnt a l
. 0
pg. ****************

*********** **************** ********** ********************

aFuatun otot
Tt*2** II
************ *************** ****""**""****"*******s*

rDog0 dhtan D h g n .
***T*****"*************"a**********
ka...EO 20pm
* * * * * * a *** * * * * * * * * * * a p * * * * * * * * * * * * * * * * * * * * * ° * * * * * * * * * * * * * * * * * * * * * * * * * * Bs* ****

**************"*******

* * * * * * * e * * * * * * * *** * * * h " * a n * * * * * * * * * * * a * ** * * * * * * * * * *****ea** ****** ****** *** ************* * * * *

"************************ ******************n

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * " * * * * * * * * * * * * * * * * *s**

**************** ************* ***********************************************

******ssse * * * * * * * * * * a * * * * * * i * * * * * * * * * * * * * e a * s d * * * * * * * * * a * * * * * * * * * * * * * s * * * * * * * * *** *****

* * * * * * * * * *** *** ********************************************

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *****

***** ***********************

***********
******

* * * * * * * " ********* ****e* *** **********

***************************a"**a*s aasee
****** *****

* * * * * * * * * * * * ***** ************************************************

* * * a n a * * * * * * * * * * * * * * * * * * * * a * s s *** s * * * * * * * * * * * * a * * * * * * * * * * * * * * * * * * * * * * * * * a * * * * * *

******* * * * * * * * * * *** * * * . * * * * * * * * *** * * * * * * * * * * * * * * * * * * * * * * * a * * * * * * * * * * * * * * * * * * * *****

******* *******"* ****** *** *** *** ****** ****** *** *** *********a****************e saa nss****a*****a** * ****

****************a s o e e * * * * * * * * * * * * * * * * * * * * * * * a * * * * e * * * * * * * * * * * * * * a a * * * * * * * * * * * * * * * * * *

e*************e * ***

6. piagmosa Keperawatan
O n ata úfattu4d daa Puat Pamapasan
unasenceee
3:
******
Gunggucn MobiLitos nkd:d Danununan akuatan 0tot

********************a*******************

7. TujyanR Khusus (Alasandilakukan tindakan):

Untue LaNngonEan r a p j . . *********************aaaass******aas aassss ******aas daseas******

0abyntu uren dalam auoRN urqaraku

* a s a a s e s n s s a * * * * s s e s s a a e s s o n a s n d e s s * * * * * a s s m a v s s a s s u a v e s s s s a e s e a s a s ****sdsssasa************saeemea s e ne*eas aveacamasnsssenso c a s s s n o s u n t n e s s s e a n e u a s a a e a e s n e s n

enauBauauupeussssaue..

*********************
***********************************aaenaa**** **apsve*********sa********* ****************a*a*****a* **********e*a **a****esnoasopaan saana na aonsaa*ssasa n a a n e n a a n a e aeves

*** *** ************"*****"**************

*****************************************************************sss0s*****asssraaessanaa ss o**s sa anaossa******** *** aenenaesasas sscs ss ansseosusoann oeer

************** ****************ssssnuess**
a***rane Be aRBBeea aaan**************asa******ea*************************** *************************e*

******* *** ********e saan aa saas*s4aa*******************4a***4*****

************ ********************************a*seseaaeas *a ssssvesss*e*

* * * * p asassssnosssnave***waswvesa se *e na vosess********ase na seessnasse ataeorene asas saba*asasan esnnmere sapousossaesassesnam**assoseae nnn*asvoreaa*aansassesnaaasu a

******* ****************"*********aas se nd as suasaans1sn e**n*asasaaaa sa vs uaas saasa se s onena************************* *****e************e

Jurusen Keperawatan, Jurusan Kebldanan: laan Woter Mongsidi No. 38 Samiarida Kaimantan Timur, Kode Pos 75123, Tekepon (0541) 738153
Jurusan Anals Kesehatan: Jalan Kumia Makmur No.64 Rt. 24 Kel. Harapan Baru Kec. Loa Janan Tir
Program Studi Dipkoma II Kebldanan BalMipapan, Jalan Sorong No. 9 RT.081 Gunung Plpa Balkpapan Utara Telepon: (0542) 424704 Fax: (0542)4155S1
 KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL TENAGA KESEHATAN
POLITEKNIK KESEHATAN KALIMANTAN TIMUR
Jalan Kurnia Makmur No. 64 RT. 24 Kelurahan Harapan Baru Kecanatan 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

DIAGNOSIs IMPLEMENTASI
NO. INTERVENst EVALUASI
KEPERAWATAN SLRI
(SIKI) JAM TINDAKAN
(SDK)
L. ola napes tdclk& Polanapey(L-otmManajauaw lo001 Puaett -P uagutatan
fet dd dapar abuath dhlabuban)aloyn napcy AaO nNo polSjak-Saat bua
Pjat pamapeian ndakan Eapauosloder.ol ou) tmtas
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Satatah duiatwtoLL antfteun olen durut, aNur saartt kaftuiut tutue
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tbun bxpau o, turun, uut panuk Saupnyun
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dihara ptan tinds..ldant(a T.
uengicbnbgtn [a tuna auan an
nya isnwnn din talanya eala pe papon0-10 bs/6q uw th- S«
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du 4-Ruraurb
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ltratugi uarzdpta tinhot conhdu uut kuuptne
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|dokan ayon
L6-Puvawat L, ontgeok Sea nya
ALbun an
gatn
atn arolpti oeterafoe
onolpH Sauptng paonen
Jurusan Keperawetan, Jurun Kebdanan: lakan Woter Mongrsdi No. 36 Samarnda -Kalimantan Tmur, Kode Pas75123, Telepon (0541) 738153
uncalgahK
akmur No. 641 Rt. 24 Harapan Baru Kec. Loa Janan Ilr
Kel.Ppa Babkpapan Utaro Telepon: (06-42) 424704 Fax: (0542) 415551
Program Sudi
Program Studi Diploma
Dlploma I1 Kebldanan Ba
m Kebldanan B lkpopen,laken Sarang No. 9 RT.08 Gunung
 KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL TENAGA KESEHATAN
POLITEKNIK KESEHATAN KALIMANTAN TIMUR
Jalan Kumia Makmur No. 64 RT. 24 Kelurahan Harapan Baru Kecamatan Loa Janan Ilir
Samarinda Kalimantan Timur Telp (0541)738153, Faksimile (0541)768523
Laman:htp// www.poltekkes-kaltim.ac.id Surat Elektroniki poltekkes smd2007@yaho.co.id
ASUHAN KEPERAWATAN

NO. DIAGNOSIs INTERVENSI IMPLEMENTASI

KEPERAWATAN SLKI EVALUASI
(SDK) (SIKI) JAM TINDAKAN

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bandin Sataa akut-kas
Aobileian
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botten uar
ntuEuuun
4. Aaurtan
|Satau alat-etn
Saccur uondm

Juruean Keperawatan, Jurusan Kebkdanan: Jalan Woter Monginsidi No. 38 Samarinda Kallmantan Timur, Kode Pos 75123, Telepon (05A1) 738153
unan Anefis Kesehtan i Jalbn Kurnia Maknur No. 64 Rt. 24 Kel. Haropan Baru Kec. Loa Janan lir
Program Studi Diploma II Kebldanen Belikpapan, Jalan Sorong No. 9 RT.081 Gunung Pipa Ballkpapan Utara Telepon:(0542) 424704 Fax : (0542) 415551