FORMAT RESUME

KEPERAWATAN MATERNITAS
PROGRAM STUDI ILMU KEPERAWATAN UNRI

A. INFORMASI UMUM
Nama : ………………………….…………………………………………………………………………………
Umur : ………………………………………………………………………………………………...............
Tanggal lahir : ……………………………………………………………………………………………..……
Jenis kelamin : ..............................................................................………………...….
Suku Bangsa : .............................................................................…………......…...…
Tanggal Masuk : ...............................................................................………………….
Tanggal Pengkajian : ………………………………………………………………………………………...
Dari/Rujukan : ………………………………………………………………………….……………………...
Diagnosa Medik : ………………………………………………………………………………..……….......
Nomor MR : ………………………………………………………………………………………

B. KELUHAN UTAMA
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C. RIWAYAT KESEHATAN SEBELUMNYA

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RIWAYAT KESEHATAN KELUARGA

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E. PEMERIKSAAN FISIK
Tanda-tanda vital :
TD :……………….....…
Suhu :……….............
Nadi :……………......… Pernafasan :…....................……………......
Tinggi Badan :..............
Berat Badan :.............
I.Kepala
1.Rambut : panjang/pendek/tanpa rambut/kotor/mudah rontok/gatal-gatal
Lain-lain :.............................................................
Masalah keperawatan :..........................................
2.Mata : Ikterik/midriasis/pakai kacamata/contact lens/gangguan penglihatan
Lain-lain :............................................................
Masalah keperawatan :........................................
3.Hidung : perdarahan/sinusitis/gangguan penciuman/malformasi/terpasang NGT
Lain-lain :...........................................................
Masalah keperawatan : .......................................
4.Mulut : Kotor/bau/terpasang ETT/Gudel/perdarahan/lidah kotor/gangguan
pengecapan
Lain-lain :..............................................................
Masalah keperawatan :...........................................
5.Gigi : Gigi palsu/kotor/kawat gigi/karies/tidak ada gigi
Lain-lain :...............................................................
Masalah keperawatan :............................................
6.Telinga : Perdarahan/terpasang alat bantu dengar/infeksi/gangguan
pendengaran
Lain-lain :.................................................................
Masalah keperawatan :.............................................
II. Leher : Pembesaran KGB/kaku kuduk/terpasang trakeostomi/
JVP :.....................................................
Lain-lain :..................................................................
Masalah Keperawatan :.................................................
III. Dada : Inspeksi :.....................................................................
Palpasi :......................................................................
Perkusi :.....................................................................
Auskultasi :..................................................................
Masalah Keperawatan :.................................................
IV. Tangan : Utuh/luka/lecet/sianosis/capllary ferill/clubbing
finger/dingin/fraktur/edema
Lain-lain :....................................................................
Masalah Keperawatan :.................................................
V. Abdomen : Inspeksi :...................................................................
Palpasi :....................................................................
Perkusi :...................................................................
Auskultasi :.................................................................
Masalah Keperawatan : ...............................................
VI. Genitalia : Perdarahan/terpasang
kateter/trauma/malformasi/menstruasi/infeksi
Lain-lain :....................................................................
Masalah keperawatan : ................................................
VII. Kaki:Fraktur/edema/malformasi/luka/infeks /keganasan /sianosis/dingin
Lain-lain :...............................................................
Masalah keperawatan :...........................................
VIII. Punggung : Lordosis/kiposis/skoliosis/luka/dekubitus/infeksi
Lain-lain :................................................................
Masalah keperawatan :............................................

Hasil Pemeriksaan Laboratorium dan Diagnostik

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Medikasi/ obat-obatan yang diberikan saat ini
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Diagnosa keperawatan
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Intervensi keperawatan