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
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.................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 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
NOC
NIC
Implementasi
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