PROGRAM PENDIDIKAN PROFESI NERS STIKES WIDYAGAMA HUSADAFORMAT PENGKAJIAN RESUME KASUS KELOLAAN HARIANKEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa:NIM:Tempat Pengkajian:Tanggal:

Identitas KlienNama : No. RM:

Umur :Pekerjaan :

Jenis Kelamin:Status Perkawinan:

Agama :Tanggal MRS:

Pendidikan :Tanggal Pengkajian:

Alamat Diagnosa Medis:

:Sumber Informasi:

Proses keperawatana. Pre operasi ( Ruang persiapan operasi)1) Data focus........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2) Diagnosa keperawatan.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3) Evaluasi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

b. Intra operasi (Ruang Operasi)1) Data Fokus........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2) Diagnosa keperawatan.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3) Intervensi /Implementasi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4) Evaluasi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

c. Post operasi (Recovery Room)1) Data Fokus........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2) Diagnosa keperawatan.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................3) Intervensi /Implementasi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4) Evaluasi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Denpasar, 2013Pengambil Data