PROGRAM STUDI S1 ILMU KEPERAWATAN

FAKULTAS KESEHATAN
ITS KESEHATAN INSAN CENDEKIA MEDIKA
JOMBANG
Jl. Kemuning No. 57 A Candimulyo Jombang, Telp. 0321-8494886

Resume Keperawatan pada Pasien................................

Dengan Diagnosa Medis..................................
Di.......................................................
I. PENGKAJIAN
A. Tanggal Masuk :
B. Jam masuk :
C. Tanggal Pengkajian :
D. Jam Pengkajian :
E. No.RM :
F. Identitas
1. Identitas pasien
a. Nama :
b. Umur :
c. Jenis kelamin :
d. Agama :
e. Pendidikan :
f. Pekerjaan :
g. Alamat :
h. Status Pernikahan:
2. Penanggung Jawab Pasien
a. Nama :
b. Umur :
c. Jenis kelamin :
d. Agama :
e. Pendidikan :
f. Pekerjaan :
g. Alamat :
h. Hub. Dengan Pasien:

G. Pengkajian
1. Primary Survey
a. Airway
1) Posisi kepala :
2) Secret/sputum :
3) Reflek batuk :
4) Lidah jatuh :
5) Benda asing :
6) Gigi :
7) Epistaksis :
8) Data lain :
b. Breathing
1) Frekuensi nafas :
2) Irama nafas :
3) Suara nafas :
4) Kedalaman nafas :
5) Pola nafas :
6) Jenis pernafasan :
7) Suara tambahan :
8) Ekspansi dada :
9) Batuk :
10) Data lain :

Dep. Keperawatan Kritis & KMB STIKES ICME Jombang

 c. Circulation
1) Tekananan darah :
2) Bunyi jantung :
3) Akral :
4) Sianosis :
5) CRT :
6) Suhu :
7) Odem :
8) Tremor :
9) Data lain :
d. Disability
1) Kesadaran :
2) GCS :
3) Respon nyeri :
4) Respon bicara :
5) Reflek pupil :
6) Spasme otot:
7) Parastesia :
8) ROM :
9) Data lain
e. Exposure
1) Cedera :
2) Kerusakan jaringan :
3) Dislokasi :
4) Luka :
5) Odem :
6) Data lain :
2. Secondary Survey
a. Keadaan Umum
Status gizi : Gemuk Normal Kurus

Berat Badan :.............................Tinggi Badan :..................................

Sikap : Tenang Gelisah Menahan nyeri

b. Keluhan Utama
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c. Riwayat Penyakit Sekarang
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d. Riwayat Penyakit Dahulu
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e. Terapi Medik
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Dep. Keperawatan Kritis & KMB STIKES ICME Jombang

II. ANALISA DATA
NO. DATA ETIOLOGI MASALAH

Dep. Keperawatan Kritis & KMB STIKES ICME Jombang

III. DIAGNOSA KEPERAWATAN (SESUAI PRIORITAS)
1. .........................................................................................................................
2. .........................................................................................................................
3. .........................................................................................................................
4. .........................................................................................................................

IV. RENCANA TINDAKAN KEPERAWATAN

NO. DIAGNOSA SLKI SIKI
KEPERAWATAN (SMART)
(SDKI)

Dep. Keperawatan Kritis & KMB STIKES ICME Jombang

I. IMPLEMENTASI
NO. HARI/ JAM TINDAKAN KEPERAWATAN PARAF

DX TGL

II. EVALUASI
NO. NO. DX HARI/ JAM EVALUASI PARAF

TGL

S:

O:

A:

P:

Dep. Keperawatan Kritis & KMB STIKES ICME Jombang