PROGRAM STUDI PENDIDIKAN NERS

FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

RESUME KEPERAWATAN
Tanggal/Jam MRS : Diagnosis Medis :
Tanggal/JamPengkajian :

I. IDENTITAS PASIEN
Nama Pasien :
Umur :
Agama :
Pendidikan :
Alamat :
Sumber Biaya :

II. KELUHAN UTAMA

……………………………………………………………………………………………………….
……………………………………………………………………………………………………….

III. RIWAYAT PENYAKIT SEKARANG

……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….

IV. PENGKAJIAN DATA FOKUS

………………………………………………………………………………...............................................
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V. WOC KASUS

VI. PRIORITAS DIAGNOSIS KEPERAWATAN:

1.

2.

3.
 PROGRAM STUDI PENDIDIKAN NERS
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

Tanggal/Jam MRS : Diagnosis Medis :
:
Tanggal/JamPengkajian

IDENTITAS PASIEN
7. Nama Pasien :
8. Umur :
9. Suku/ Bangsa :
10. Agama :
11. Pendidikan :
12. Pekerjaan:

13. Alamat :
14. Sumber Biaya :

KELUHAN UTAMA
1. Keluhan utama:………………………………………………………………………………………
……………………………………………………………………………………………………….

RIWAYAT PENYAKIT SEKARANG/MECHANISM OF INJURY/EVENT

………………………………………………………………………………......................................
…………………………………………………………………………………………………………
…..........................................................................................................................................................
…………………………………………………………………………………………………………
…..........................................................................................................................................................

OBSERVASI DAN PEMERIKSAAN FISIK

1. Triage : Biru Merah Hijau Kuning
2. Kesadaran (Alert, Verbal, Pain, Unresponsive):
3. Tanda tanda vital
S: N: T: RR : SpO2:

4. Keluhan Nyeri: ya tidak

P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
Pengkajian skala nyeri dengan Wong Baker
 T :...................................................................

5. Airway dan C Spine Control/ Immobilization

a. Jalan Nafas , bebas ya tidak
b. Obstru ksi/ Sumbatan tidak sebagian total
c. Benda Asing tidak padat cair
Berupa : …………………..
d. Mulut, terkatup tidak ya
e. Batuk produktif tidak produktif
Sekret:…….. Konsistensi :......................
Warna:.......... Bau :..................................

f. Jejas yang mendukung kecurigaan fr.tulang servikal: ......................................................

...........................................................................................................................................
6. Breathing
a. Normal ya tidak
b. Keluhan:: sesak tidak ya nyeri waktu nafas orthopnea
waktu istirahat beraktifitas
c. RR:
d. Pergerakan dada simetris asimetris
e. Penggunaan otot bantu nafas: tidak ya
Jenis:.............................................................................................................................................

f. Irama nafas teratur tidak teratur

 g. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot
h. Suara nafas Vesikuler Bronko vesikuler Crackles
Ronki Wheezing
i. Suara perkusi paru sonor hipersonor redup
j. Kelainan tulang dada: .................................................................................................................
k. Data tambahan:
………………………………………………………………………………………

7. Circulation
a. Nadi Karotis: teraba tidak
Nadi Perifer: kuat lemah tidakteraba
Perdarahan:............... cc Lokasi .............
b. Irama jantung: reguler ireguler
c. Suara jantung: normal (S1/S2 tunggal) murmur
d. Ictus Cordis: gallop lain-lain.....
. . . . . .. . ... . . . . . .. . . . . . . . . . . . . . .. . . . . . .. . . . .. . .. . . .. . . .. . . . . . .. . . .. . . . . . .. . . . . . .. . . .. . . . . . .. . . .. . . .. . . .. . . . . . . . . .. . .

e. CRT.............. detik
f. Turgor normal turun/ lambat kembali
g. Akral/ perfusi: hangat kering merah basah pucat dingin
h. ECG & Interpretasinya:
........................................................................................................................................................
........................................................................................................................................................
i. Data tambahan:
........................................................................................................................................................
........................................................................................................................................................

8. Disability
a. Kesadaran Compos Mentis Apatis Somnolen Sopor Koma
b. Gelisah tidak ya
c. GCS : ……… ( E: ……., V: ……., M ........... . )
d. Refleks cahaya: …………../ ……………
e. Pupil isokor anisokor Diameter: …………../ .................. Mm
f. Kejang tidak ya
g. Hemiparese/ plegia tidak ya (Ekstremitas kiri/ kanan), tetraplegi
h. Refleks fisiologis patella t riceps biceps
i. Refleks patologis babinsky oppenheim schaefer
Meningeal Sign kaku kuduk brudzinsky kernig
Lain-lain
j. Tanda PTIK Muntah proyektil nyeri kepala hebat. Lain-lain .....................
k. CurigaFrakturcervikal jejas atas klavikula multiple trauma, Lain-lain .....................
l. Tanda Fraktur Basis Cranii
Bloody rinorhoe Bloody otorhoe
Brill Hematoma Batle Sign
m. Data tambahan:
........................................................................................................................................................
........................................................................................................................................................
9. Exposure
Bone dan Integumen
a. Perubahan bentuk : ada tidak
Lokasi/deskripsi: ........................................................................................................... ......

b. Tumor/benjolan: ada tidak

Lokasi/desk ripsi: .......................................................................................................... .......

c. Luka: ada tidak

Lokasi/deskripsi: ............................................................................................................ .....

d. Pergerakan sendi: bebas terbatas

e. Kekuatan otot:

f. Kelainan ekstremitas: ya tidak

g. Kelainantulang belakang ya tidak
Frankel: ................................................................................

h. Fraktur: ya tidak
- Jenis :...................
i. Traksi: ya tidak
- Jenis :................... Beban :...................
 - Lama pemasangan :...................
j. Penggunaan spalk/gips: ya tidak
k. Sirkulasi perifer:
............................................. .
l. Kompartemen syndrome ya tidak
m. Kulit: ikterik sianosis kemerahan hiperpigmentasi

Turgor baik kurang jelek

Pitting edema: +/- grade:................

Ekskoriasis: ya tidak
Urtikaria: ya tidak

n. Luka operasi: ada tidak

Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
o. ROM : ................................................

p. Data tambahan:

.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

10. Eliminasi
URI

a. Normal : ya tidak
b. Keluhankencing: Ada Tidak
Bila ada, jelaskan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

c. Kemampuan berkemih:
Spontan Alat bantu, sebutkan: .......................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
d. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
e. Kandung kemih : Membesar ya tidak
Nyeri tekan ya tidak

ALVI

a. Normal ya tidak
b. Mulut: bersih kotor berbau
c. Membran mukosa: lembab kering stomatitis
d. Tenggorokan:
s akit menelan kesulitan menelan
p mbesaran tonsil nyeri tekan
e. Abdomen: tegang kembung ascites, lingkar abdomen
….. cm
Nyeri tekan: ya tidak
f. Peristaltik: .............. x/menit suara bising usus hipoaktif hiperaktif
g. BAB....................... x/hari Terakhir tanggal : ..............
h. Keluhan BAB, jelaskan:
....................................................................................................................................... ................
.......................................................................................................................................................
 .......................................................................................................................................................
11. Sistem Endokrin
a. Pembesaran tyroid: ya tidak
 b. Pembesaran kelenjar getah bening: ya tidak
c. Hipoglikemia: ya tidak, Nilai:
d. Hiperglikemia: ya tidak, Nilai:

e. Data tambahan:..................Jelaskan:..................................................
TB :............... BB :................................
IMT :............... Interpretasi :................................
LOLA :...............

ANAMNESA AMPLE (Allergy, Medication, Past Medical History, Last

Meal, Event/kejadian):
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

PEMERIKSAAN RISIKO JATUH

Pemeriksaan Risiko Jatuh Morse
Faktor Risiko Skala Poin Skor Kesimpulan/
Pasien Masalah
Riwayat Jatuh Ya, dalam 3 bulan terakhir 25
Tidak
Diagnosis Sekunder (≥ Ya 15
diagnosis medis) Tidak 0
Alat Bantu Perabot
Tongkat/ Alat Penopang
Tidak Ada/ kursi roda/
perawat/ tirah baring
Terpasang Infus/ terapi Ya 20
intravena Tidak 0
Gaya Berjalan Terganggu/ kerusakan 20
kelemahan 10
Normal/ tirah baring/ 0
imobilisasi
Status Mental Sering lupa akan keterbatasan 15
yang dimiliki/ tidak konsisten
dengan perintah
Orientasi baik terhadap 0
kemampuan diri sendiri
Catatan Total

PENGKAJIAN PSIKOSOSIAL
Jelaskan data subyektif dan obyektif terkait masalah psikososial yang ditemukan
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah

b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
PEMERIKSAAN PENUNJANG (Laboratorium, Radiologi, EKG, USG, dll):

TERAPI :

Surabaya,

( ...............................................)
 PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

ANALISIS DATA

DATA ETIOLOGI MASALAH

 PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

TANGGAL: .................................
1.

2.

3.

4.

5.

6.
 INTERVENSI DAN IMPLEMENTASI

DIAGNOSA Paraf Paraf

TGL KEPERAWATAN JAM INTERVENSI/IMPLEMENTASI EVALUASI
(Tujuan, Kriteria Hasil)
Tanggal..... Jam.....

S:

O:

A:

P:
 DIAGNOSA Paraf Paraf
TGL KEPERAWATAN JAM INTERVENSI/IMPLEMENTASI EVALUASI
(Tujuan, Kriteria Hasil)
 DIAGNOSA Paraf Paraf
TGL KEPERAWATAN JAM INTERVENSI/IMPLEMENTASI EVALUASI
(Tujuan, Kriteria Hasil)
 PROGRAM STUDI PENDIDIKAN NERS
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

FORMAT PENGKAJIAN KEPERAWATAN KRITIS

Tanggal MRS : Jam Masuk :
Tanggal Pengkajian : No. RM :
Jam Pengkajian : Diagnosa Medis:
Hari rawat ke :

IDENTITAS
1. Nama Pasien :
2. Umur :
3. Suku/ Bangsa :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :
8. Sumber Biaya :

KELUHAN UTAMA
Keluhan utama:………………………………………………………………………………………
……………………………………………………………………………………………………….

RIWAYAT PENYAKIT SEKARANG

1. Riwayat PenyakitSekarang:
………………………………………………………………………………......................................
…………………………………………………………………………………………………………
…..........................................................................................................................................................
…………………………………………………………………………………………………………
…..........................................................................................................................................................

RIWAYAT PENYAKIT DAHULU

1. Pernah dirawat : ya tidak kapan :……diagnosa :…………
2. Riwayat penyakit kronik dan menular ya tidak jenis……………………
Riwayat kontrol : .............................
Riwayat penggunaan obat :..............
3. Riwayat alergi:
Obat ya tidak jenis……………………
Makanan ya tidak jenis……………………
Lain-lain ya tidak jenis……………………
4. Riwayat operasi: ya tidak
- Kapan : ……………………
- Jenis operasi : ……………………

5. Data tambahan:
................................................................................................................................................................
.................................................................................................................................................................
................................................................................................................................................................

RIWAYAT KESEHATAN KELUARGA

Ya tidak
- Jenis :…………………........................................................................
PERILAKU YANG MEMPENGARUHI KESEHATAN
Perilaku sebelum sakit yang mempengaruhi kesehatan:
Alkohol ya tidak
keterangan…………………….........................................................
Merokok ya tidak
keterangan…………………….........................................................
Obat ya tidak
keterangan…..............................................................………………
Olahraga ya tidak
keterangan…..........................................................…………………

OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda tanda vital
S: N: T: RR :
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma
a. Keluhan nyeri: ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S : Skala nyeri menggunakan CPOT : ...........................

T :...................................................................
2. Sistem Pernafasan (B1)
Jalan Nafas , bebas ya tidak
Obstruksi tidak sebagian total
Benda Asing tidak padat cair
Berupa : …………………..
a. RR:................................
b. Keluhan:: sesak tidak ya nyeri waktu nafas orthopnea
Batuk produktif tidak produktif
a. Sekret:…….. Konsistensi :......................
b. Warna:.......... Bau :..................................
c. Pergerakan dada simetris asimetris
d. Penggunaan otot bantu nafas: tidak ya
e. Jenis:.............................................................................................................................................
f. Irama nafas teratur tidak teratur
g. Pleural Friction rub:.....................................................................................................................
h. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot
i. Suara nafas Vesikuler Bronko vesikuler Cracles
Ronki Wheezing
j. Suara perkusi paru sonor hipersonor redup
k. Alat bantu napas ya tidak

Jenis................................................ Flow .............. lpm

Ventitalor tidak ya
Mode :
FiO2 :
PEEP :
SaO2 :
Vol. Tidal:
I:E Ratio:
Data tambahan:

l. Penggunaan WSD:
- Jenis : ......................................................................................................................
- Jumlah cairan : ......................................................................................................................
- Undulasi :...... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... ....

- Tekanan : ............ .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... ..

m. Tracheostomy: ya tidak
........................................................................................................................................................
.......................................................................................................................................................
n. Data tambahan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
3. Sistem Kardio vaskuler (B2)
Nadi Karotis: teraba tidak
Nadi Perifer: kuat lemah tidak teraba
Perdarahan: ............... cc Lokasi .............
Keluhan nyeri dada: ya tidak
Irama jantung: reguler iregule
Suara jantung: normal (S1/S2 tunggal) murmur
gallop lain-lain.....
Ictus Cordis:
CRT.............. detik
Turgor normal turun
Akral: hangat kering merah basah pucat dingin

Sikulasi perifer: normal menuru

JVP :.................................

CVP :.................................

CTR :.................................

ECG & Interpretasinya:

........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
 ........................................................................................................................................................
........................................................................................................................................................
Data tambahan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

4. Sistem Persyarafan (B3)

a. GCS : ..................................................
b. Refleks fisiologis patella triceps biceps
c. Refleks patologis babinsky oppenheim schaefer
Meningeal Sign kaku kuduk brudzinsky kernig
Lain-lain
d. Keluhan pusing ya tidak

e. Pemeriksaan saraf kranial:

N1 : normal tidak Ket.: ……..............................................................
N2 : normal tidak Ket.: ……..............................................................
N3 : normal tidak Ket.: ……..............................................................
N4 : normal tidak Ket.: ……..............................................................
N5 : normal tidak Ket.: ……..............................................................
N6 : normal tidak Ket.: ……..............................................................
N7 : normal tidak Ket.: ……..............................................................
N8 : normal tidak Ket.: ……..............................................................
N9 : normal tidak Ket.: ……..............................................................
N10 : normal tidak Ket.: ……..............................................................
N11 : normal tidak Ket.: ……..............................................................
N12 : normal tidak Ket.: ……..............................................................

f. Pupil anisokor isokor Diameter: ……/......

g. Tanda PTIK Muntah proyektil nyeri kepala hebat. Lain-lain .....................
h. Curiga Fraktur cervikal jejas atas klavikula multiple trauma, Lain-lain .....................
i. Tanda Fraktur Basis Cranii
Bloody rinorhoe Bloody otorhoe
Brill Hematoma Batle Sign
j. Isitrahat/Tidur................... Jam/Hari Gangguan tidur : ........................
k. ICP :................................................
l. Data tambahan:

........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
.......................................................................................................................................................

5. Sistem perkemihan (B4)

b. Kebersihan genetalia: Bersih Kotor
c. Sekret: Ada Tidak
d. Ulkus: Ada Tidak
e. Kebersihan meatus uretra: Bersih Kotor
f. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

g. Kemampuan berkemi h:
Spontan Alat bantu, sebutkan: .......................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
h. Produksi urine : ………….. ml/jam
Warna :............…… Bau :......………..
 i. Kandung kemih : Membesar ya tidak
Nyeri tekan ya tidak
j. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
k. Data tambahan:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

6. S
a.istTeB
m pence:.r..n..a..a..n. (.B5) BB :................................

b. IMT :............... Interpretasi :................................

c. LOLA :............... .
d. Mulut: bersih kotor berbau
lembab
e. Membran mukosa: kering stomatitis
f. Tenggorokan:
sakit menelan kesulitan menelan
pembesaran tonsil nyeri tekan
g. Abdomen: tegang kembung ascites, lingkar abdomen ….. cm
Nyeri tekan: ya tidak
Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................

- Warna :...................

- Kondisi area sekitar insersi :...................

h. Peristaltik .............. x/menit
i. BAB: ...................... x/hari Terakhir tanggal: ..............
j. Konsistensi: keras lunak cair lendir/darah
k. Diet: pada lunak cair

l. Diet Khusus:
........................................................................................................................................................
....................................................................................................
m. Nafsu makan: baik menurun Frekuensi....... x/hari
Keterangan:
n. Porsi makan: habis tidak .......................
o. Data tambahan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

7. Sistem muskuloskeletal (B6)

a. Pergerakansendi: bebas terbatas
b. Kekuatan otot:

c. Kelainan ekstremitas: ya tid k

d. Kelainantulangbelakang : ya tid k
................................................................................Frankel:

e. Fraktur: ya tidak
- Jenis :................. .
f. Traksi: ya tidak
- Jenis :................. .
- Beban :................. .

- Lama pemasangan :................. .

g. Penggunaan spalk/gips: ya tidak
h. Sirkulasi perifer:
............................................. . j. K l t: ikterik
i. Kompartemen syndrome ya
kurang u i k. Turgor baik
l. Luka operasi: ada
tidak
sianosis kemerahan hiperpigmentasi
jelek
tidak

Tanggal operasi :................ Jenis operasi :................ Lokasi :................

 Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
m. ROM : ................................................

n. Data tambahan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

o. Pitting edema: +/- grade:................

p. Ekskoriasis: ya tidak
q. Urtikaria: ya tidak
r. Data tambahan:
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
PEMERIKSAAN RISIKO
JATUH Morse Fall Scale (MSF)
Faktor Risiko Skala Poin Skor Kesimpulan/
Pasien Masalah
Riwayat Jatuh Ya 25
Tidak
Diagnosis Sekunder (≥ Ya
diagnosis medis) Tidak
Alat Bantu Perabot
Tongkat/ Alat Penopang
Tidak Ada/ kursi roda/
perawat/ tirah baring
Terpasang Infus Ya
Tidak
Gaya Berjalan Terganggu
Lemah
Normal/ tirah baring/
imobilisasi
Status Mental Sering lupa akan
keterbatasan yang
dimiliki
Orientasi baik terhadap
kemampuan diri sendiri
Catatan Total

8. Sistem Endokrin
a. Pembesaran tyroid: ya tidak
b. Pembesaran kelenjar getah benin ya tidak
c. Hipoglikemia: ya tidak, Nilai:
d. Hiperglikemia: ya tidak, Nilai:

e. Data tambahan:.................. Jelaskan:..................................................

PENGKAJIAN PSIKOSOSIAL
Persepsi klien terhadap penyakitnya:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

Ekspresi klien terhadap penyakitnya

Murung/diam gelisah tegang marah/menangis
Reaksi saat interaksi kooperatif tidak kooperatif curiga
 Gangguan konsep diri:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

Data tambahan:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

PERSONAL HYGIENE & KEBIASAAN

Jelaskan

PENGKAJIAN SPIRITUAL
Kebiasaan beribadah
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah

Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)

TERAPI

DATA TAMBAHAN LAIN :

Surabaya, ……………..20...

(………………………)
 PROGRAM STUDI PENDIDIKAN NERS
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

ANALISIS DATA

TANGGAL DATA ETIOLOGI MASALAH

 PROGRAM STUDI PENDIDIKAN NERS
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

TANGGAL: .................................
1.

2.

3.

4.

5.

6.
 RENCANA INTERVENSI

HARI/ DIAGNOSA KEPERAWATAN

TANGGAL WAKTU (Tujuan, Kriteria Hasil) INTERVENSI RASIONAL
 HARI/ DIAGNOSA KEPERAWATAN
TANGGAL WAKTU (Tujuan, Kriteria Hasil) INTERVENSI RASIONAL
 HARI/ DIAGNOSA KEPERAWATAN
TANGGAL WAKTU (Tujuan, Kriteria Hasil) INTERVENSI RASIONAL
 LOGBOOK KEGIATAN PROFESI KEPERAWATAN GADAR DAN KRITIS
PROGRAM ALIH JENIS B24
PROGRAM PROFESI NERS
FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

Periode Praktik :
Ruangan :
Pendidik klinis :

Hari/ NO Uraian Kegiatan Kendala Rencana Tindak Paraf Paraf

Tanggal/Jam Lanjut mahasiswa Pendidik
Klinis
 Mengetahui, Pembimbing Akademik
KPS Ners

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