FORMAT
RESUME ASUHAN KEPERAWATAN
KEPERAWATAN
MEDIKAL BEDAH
Nama
Mahasiswa : ………………………………………..
Tempat
Praktek : ………………………………………..
Tanggal
: ………………………………………..
I. Identitas diri
klien
|
Nama : ………………………
Umur : …………………….....
Jenis
Kelamin : …………………….....
Alamat :
……………………….
Status Perkawinan
: ……………………….
Agama
: ……………………….
Suku : ………………………..
|
|
Pendidikan
: ……………………......
Pekerjaan
: ………………….........
Lama
Bekerja : ………………….........
Tanggal
Masuk RS :……………………......
Tanggal
Pengkajian :……………………......
Sumber
Informasi :……………………......
|
II. Riwayat Penyakit
1. Keluhan utama saat masuk RS
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………........
2. Riwayat penyakit sekarang
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3. Riwayat
penyakit dahulu
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………................................................
Diagnosa Medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah
dilakukan
( informasikan tentang pemeriksaan penunjang dan kesimpulan
hasilnya serta tindakan yang telah dilakukan dari saat MRS sampai hari
pengambilan klien sebagai kasus kelolaan )
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………................................................
III. Pengkajiaan saat ini
1. Persepsi dan Pemeliharaan kesehatan
Pengetahuan
tentang penyakit / perawatan
…………………………………………………………………………………………………………………………………………………………………………………….......................
…………………………………………………………………………………………………
Pola
nutrisi / metabolik
Program di
rumah sakit ……………………………………………………………………………………..………………………………………………………………………………………………................................................................................................................................................................................
Intake
makanan ……………………………………………………………………………………………………………………………………………..………………………….….……………………………………..…………………………………………………………......................................
Intake
cairan ……………………………………………………………………………………………………………………………………………………………………………………........................
…………………………………………………..…………………………..…………………
2. Pola
eliminasi
a.
Buang air besar
……………………………………………………………………………………………………………………………………………..………………………..………………………………………………………………………………………………………
b.
Buang air kecil
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3. Pola Aktivitas dan Latihan
|
Kemampuan perawatan diri
|
0
|
1
|
2
|
3
|
4
|
|
Makan /
minum
|
|||||
|
Toileting
|
|||||
|
Berpakaian
|
|||||
|
Mobilitas
di tempat tidur
|
|||||
|
Berpindah
|
|||||
|
Ambulasi /
ROM
|
0 :
mandiri, 1 : dengan alat bantu, 2 : dibantu orang lain, 3 : dibantu orang lain
dan alat, 4 : tergantung total
Oksigenasi ………………………………………………………………………………………..………………………………………………………………………………………………….
.......................................................................................................................................
4. Pola
tidur dan istirahat
(lama tidur,
gangguan tidur, perasaan saat bangun tidur)
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
5. Pola
Peceptual
(penglihatan,
pendengaran, pengecap, sensasi)
................................................................................................................................................................................……………………………………………………………………………………………………………………………………………………………………………………
6. Pola
Persepsi diri
(pandangan
klien tentang sakitnya, kecemasan, konsep diri)
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
7. Pola
seksualitas dan reproduksi
(fertilitas, libido, menstruasi, kontrasepsi, dll)
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………
8. Pola peran
dan hubungan
(komunikasi, hubungan dengan orang lain, kemampuan keuangan)
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
9. Pola
Managemen koping stress
(perubahan terbesar dalam hidup pada akhir-akhir ini)
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
10. Sistem nilai
dan kepercayaan
(pandangan klien tentang agama, kegiatan keagamaan , dll)
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Pemeriksaan
Fisik
(Cephalocaudal)
Keluhan yang
dirasakan saat ini
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
TD
: mmHg
P :
x/menit
N :
x/menit
S
:
ºC
BB : kg
TB
: cm
Kepala:
………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………..………………………………………………………………………………………..……………………………
Leher:
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Thorak:
………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………..
Abdomen:
………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
Inguinal:
……………………………………………………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………………………………………
Ekstrimitas
(termasuk keadaan kulit, kekuatan):
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
Program
terapi:
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Hasil Pemeriksaan Penunjang dan laboratorium
(dimulai
saat anda mengambil sebagai kasus kelolaan, cantumkan tanggal pemeriksaan dan
kesimpulan hasilnya)
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
IV.
Analisa Data
|
No
|
Data
Penunjang
|
Masalah
|
Kemungkinan
penyebab
|
|
|
|
Diagnosa
Keperawatan
1.
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………........................
2.
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
3.
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
4.
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
5.
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
6.
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
