Format Longcase.docx

ASUHAN KEPERAWATAN LONG CASE & MINI CEX RUMAH SAKIT UMUM DAERAH ULIN BANJARMASIN DI RUANG DAHLIA (PARU)

Nama Mahasiswa

: Nahdiah, S. Kep

NPM

: 1614901210744

Ruang

: Dahlia (Paru)

CI

CT

Nama Klien

: ......................................................................

Umur/ tgl lahir

: ......................................................................

Diagnosa Medis

: ......................................................................

Tanggal Pengkajian

: Jum’at, 19 Januari 2018

Riwayat keluahan saat pengkajian

: ......................................................................

.................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... DATA FOKUS: a. Data Subjektif ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. b. Data Objektif ............................................................................................................................. ............................................................................................................................. .............................................................................................................................

............................................................................................................................. ............................................................................................................................. ............................................................................................................................. .............................................................................................................................  Inspeksi ........................................................................................................................ ........................................................................................................................ ........................................................................................................................  Palpasi ........................................................................................................................ ........................................................................................................................ ........................................................................................................................  Perkusi ........................................................................................................................ ........................................................................................................................ ........................................................................................................................  Auskultasi ........................................................................................................................ ........................................................................................................................ ........................................................................................................................

ANALISA DATA : DATA Data Subjektif: ........................................................................... ........................................................................... ........................................................................... ........................................................................... ........................................................................... ........................................................................... ........................................................................... ........................................................................... Data Objektif: ........................................................................... ........................................................................... ........................................................................... ........................................................................... ........................................................................... ........................................................................... ...........................................................................

PROBLEM

ETIOLOGI

PROSES ASUHAN KEPERAWATAN (INTERVENSI, IMPLEMENTASI DAN EVALUASI) Diagnosa Keperawatan

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