format resum askep
TRANSCRIPT
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RESUM ASKEP
PRAKTIK NERS STAGE KEPERAWATAN MEDIKAL BEDAH
STIKES MUHAMMADIYA BANJARMASIN
NAMA MAHASISWA :
N P M :
TEMPAT PRAKTIK :
TANGGAL :
1. IDENTITAS KLIEN
a.Nama klien : ______________________________________________________
b. Umur : ______________________________________________________
c. Jenis kelamin : ______________________________________________________
d.
Diagnosis medis : ______________________________________________________e. Tanggal pengkajian : ______________________________________________________
2. KELUHAN UTAMA
a. Data subjektif
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b. Data objektif
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c. Pengkajian nyeri (PQRST)
P _______________________________________________________________________
Q _______________________________________________________________________
R _______________________________________________________________________
S _______________________________________________________________________
T _______________________________________________________________________
3. DATA FOKUS PEMERIKSAAN FISIK
a. Inspeksi
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________________________________________________________________________b. Palpasi
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PARAF CI
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c. Perkusi
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d.
Auskultasi
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e. Tanda-tanda vital
Tekanan darah : _______________________________________________________
Denyut nadi : _______________________________________________________
Respirasi : _______________________________________________________
Temperatur : _______________________________________________________Saturasi oksigen : _______________________________________________________
4. ANALISA DATA
DATA ETIOLOGY MASALAH
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5. DIAGNOSA KEPERAWATAN
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a. Tujuan
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b. Kriteria hasil
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6 INTERVENSI KEPERAWATAN
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6.
IMPLEMENTASI
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7. EVALUASI
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