FORMAT RESUME

Nama : Ruangan :
Waktu praktek : Pembimbing :

A. IDENTITAS KLIEN

Nama : Pendidikan :
Umur : Pekerjaan :
Jenis Kelamin : Dx Medis :
Alamat : Tgl RMS :
Status Perkawinan : No. RM :
Agama : Tgl pengkajian :
Suku : Jam Pengkajian :

B. RIWAYAT PENYAKIT
1. Riwayat Penyakit Sekarang
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2. Riwayat Kesehatan dulu
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3. Riwayat Kesehatan Keluarga
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4. Riwayat Alergi
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C. PENGKAJIAN KEPERAWATAN
1. Persepsi dan Pemeliharaan Kesehatan
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2. Pola Nutrisi/Metabolik
Intake Makanan : .......................................................................................................
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Intake Cairan : ...........................................................................................................
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3. Pola Eliminasi
Buang Air Besar : ......................................................................................................
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Buang Air Kecil : ......................................................................................................
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4. Pola Aktifitas dan Latihan

Kemampuan Perawatan Diri 0 1 2 3 4

Makan/minum
Mandi
Toiletting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi/ROM

Ket :

a. 0 : mandiri d. 3 : dibantu orang lain dan alat

b. 1 : alat bantu e. 4 : ketergantungan total
 c. 2 : dibantu orang lain
Oksigenasi : ...............................................................................................................
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5. Pola Tidur dan Istirahat (lama tidur, gangguan tidur, perasaan saat bangun tidur)
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6. Pola Perceptual (pengelihatan, pendengaran, pengecap, sensasi)
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7. pola Persepsi Diri (pandangan klien tentang sakitnya, kecemasan, konsep diri)
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8. Pola Peran Hubungan (komunikasi, hubungan dengan orang lain, kemampuan
keuangan)
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9. Pola Seksualitas dan Reproduksi (fertilitas, libido, menstruasi, kontrapsepsi, dll)
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10. Pola Manajemen Koping-Stres (perubahan terbesar dalam hidup akhir-akhir ini)
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11. Sistem Nilai dan Keyakinan (pandangan klien tentang agama, kegiatan tentang
keagamaan, dll )
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D. PEMERIKSAAN FISIK
1. Cephalocaudal
a. Keluhan yang dirasakan saat ini : ........................................................................
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b. TD :
R:
N:
S:
c. BB/TB : ...............................................................................................................
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d. Kepala :................................................................................................................
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e. Leher : .................................................................................................................
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f. Thoraks : ..............................................................................................................
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g. Ingual : .................................................................................................................
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h. Ekstermitas (termasuk keadaan kulit dan kekuatan) : .........................................
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2. Penanganan Kasus : ...................................................................................................
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E. TERAPI :
1. Terapi Obat : .............................................................................................................
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2. Terapi Suportif :.........................................................................................................
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