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Oleh:
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Telah disahkan dan diterima oleh Clinical Instructure (CI) dan Clinical Teacher (CT)
Keperawatan Gadar sebagai syarat memperoleh nilai dari Departement Keperawatan Gadar
Akper RS. Efarina Purwakarta.
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Clinical Instructure (CI) Clinical Teacher (CT)
Ruang ............................................. Akper RS. Efarina Purwakarta
RSU .............................................
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NIP. NIK.
AKADEMI KEPERAWATAN RS. EFARINA
JALAN BUNGURSARI NO. 1 CIBENING - PURWAKARTA
RESUME KEPERAWATAN
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Allergi :
Medication/ Pengobatan :
ada
Turgor : Elastis Lambat
Diaphoresis: Ya Tidak
Riwayat Kehilangan cairan berlebihan: Diare Muntah Luka
bakar
Keluhan Lain: ... ...
Masalah Keperawatan:
Jalan Nafas : Paten Tidak Paten
Obstruksi : Lidah Cairan Benda Asing
Tidak Ada Muntahan Darah Oedema
Suara Nafas : Snoring Gurgling Stridor Tidak ada
AIRWAY
Masalah Keperawatan:
Kesadaran:
Composmentis Delirium Somnolen Apatis Koma
GCS : Eye ... Verbal ... Motorik ...
Pupil : Isokor Unisokor Pinpoint Medriasis
Refleks Cahaya: Ada Tidak Ada
DISABILITY
Masalah Keperawatan:
Deformitas : Ya Tidak Lokasi ... ...
EXPOSURE
b. Wajah :
c. Mata:
d. Hidung:
e. Mulut :
f. Telinga :
Leher :
HEAD TO TOE
Dada :
Ekstremitas :
Masalah Keperawatan:
1) ................................................................................................................................................
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2) ................................................................................................................................................
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3) ................................................................................................................................................
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4. INTERVENSI KEPERAWATAN
No Tgl/
Diagnosa Implementasi dan respon Paraf
jam
6. EVALUASI KEPERAWATAN
No Tgl /
Diagnosa Keperawatan Catatan Perkembangan (SOAP) Paraf
jam
AKADEMI KEPERAWATAN RS. EFARINA
JALAN BUNGUR SARI NO. 1 CIBENING - PURWAKARTA
ASUHAN KEPERAWATAN
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Diaphoresis: Ya Tidak
Riwayat Kehilangan cairan berlebihan: Diare Muntah Luka
bakar
IVFD : Ya Tidak, Jenis cairan: … …
Lain: ... ...
Masalah Keperawatan:
Masalah Keperawatan:
Nyeri : Ada Tidak
Problem : ... ... Qualitas/ Quantitas : ... ...
Regio : ... ... Skala : ... ...
Timing : ... ...
Kekuatan otot : ... ...
Masalah :
PEMERIKSAAN LABORATORIUM
Tanggal :
Jenis Pemeriksaan :
No Hasil Normal Satuan
Tanggal :
Jenis Pemeriksaan :
No Hasil Normal Satuan
Tanggal :
Jenis Pemeriksaan :
No Hasil Normal Satuan
2. ANALISA DATA
1) ................................................................................................................................................
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2) ................................................................................................................................................
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3) ................................................................................................................................................
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4. INTERVENSI KEPERAWATAN
No Tgl/
Diagnosa Keperawatan Implementasi dan Respon Paraf
jam
6. EVALUASI KEPERAWATAN