FORMAT RESUME KEPERAWATAN ANAK

PROGRAM STUDI NERS FAKULTAS ILMU KESEHATAN

UNIVERSITAS PAHLAWAN

Nama Mahasiswa : Tgl Pengkajian:

Ruangan : Ruangan :

PENGKAJIAN

1. Data Umum Pasien

a. Nama Pasien (inisial) :
b. Umur :
c. Jenis Kelamin :
d. NO MR :
e. Tanggal masuk RS :
f. Penanggung Jawab Pasien :
g. Dianosis Medis :
h. Pekerjaan :
i. Alamat :

2. Alasan Masuk/Dirawat:
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3. Kondisi Penyakit Sekarang:Lokasi/Kualitas/Kuantitas/Intensitas/Waktu/Awitan/Situasi
ketika keluhan atau gejala muncul/Faktor yang memperberat dan
meringankan/Manifestasi yang Menyertai/Kebiasaan Merokok/Alkhohol.
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4. Pemeriksaan Fisik
Tekanan Darah :
Frekuensi Napas :
Frekuensi Nadi :
Suhu :
Tanda Gejala lainnya:
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5. Pemeriksaan Laboratorium
Jenis Pemeriksaan Temuan Hasil Normal satuan

Penetalaksaan lainnya:

6. Pemberian Obat-Obatan
Tanggal Pemberian:
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 FORMAT DIAGNOSA DAN INTERVENSI KEPERAWATAN

Diagnosa Keperawatan:

NOC/SLKI NIC/SIKI
Tujuan: Intervensi:

Kriteria Hasil:

Aktivitas:
- Observasi

- Mandiri

- Edukasi

- Kolaborasi
 FORMAT IMPLEMENTASI DAN EVALUASI KEPERAWATAN

DIAGNOSA KEPERAWATAN:

TGL/ IMPLEMENTASI EVALUASI PARAF

JAM