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LAPORAN RESUME KLIEN DI POLI TUMBUH KEMBANG Nama Mahasiswa NIM Kelompok I.
: Ima Juliana, S.Kep : 1830913320003 :A
IDENTITAS DATA Nama Umur Nama Ayah/lbu Pekerjaan Ayah/Ibu Pendidikan Ayah/Ibu Alamat / No. Telpon Suku Agama Ruangan Diagnosa Medis
:.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :..............................................................................................
II. ALASAN MASUK
……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… III. RIWAYAT PENYAKIT a. Keluhan Utama ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… b. Riwayat Penyakit Sekarang ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… c. Riwayat Penyakit Dahulu ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… d. Riwayat Penyakit Keluarga ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………
IV. DATA FOKUS Inspeksi :……………………………………………………………………………… ……………………………………………………………………………… Palpasi :……………………………………………………………………………… ……………………………………………………………………………… Perkusi :……………………………………………………………………………… ……………………………………………………………………………… Auskultasi:……………………………………………………………………………… ……………………………………………………………………………… V. DATA TAMBAHAN BB =………………………………………………………………………………… TB =………………………………………………………………………………… LK =………………………………………………………………………………… LLA =………………………………………………………………………………… VI. DATA PENUNJANG NCHS a. BB/U ………………………………………………………………………………………… ……...…………………………………………………………………………………... .......................................................................................................................................... .......................................................................................................................................... b. TB/U ………………………………………………………………………………………… ……...…………………………………………………………………………………... .......................................................................................................................................... .......................................................................................................................................... c. BB/TB ………………………………………………………………………………………… ………………………………………………………………………………………….. .......................................................................................................................................... .......................................................................................................................................... d. CDC 2000 ………………………………………………………………………………………… ……..…………………………………………………………………………………... .......................................................................................................................................... ..........................................................................................................................................
VII. ANALISA DATA DATA …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. ………………………………………………….
ETIOLOGI ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ………………………..
MASALAH ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ……………………………….
VIII. RENCANA ASKEP 1. Diagnosa Keperawatan :………………………………………………............ ………………………………………………............. ………………………………………………............. 2.
Tujuan
: …………………………………………………………….. ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ………………………………………………………………
3.
Kriteria Hasil
: …………………………………………………………….. ……………………………………………………………… ……………………………………………………………… ………………………………………………………………
4.
Intervensi
: …………………………………………………………….. ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ………………………………………………………………
5.
Implementasi
: …………………………………………………………….. ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ………………………………………………………………
6.
Evaluasi S
:………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
O
:………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
A
:………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………….
P
:………………………………………………………………………………… …………………………………………………………………………………
: Ima Juliana, S.Kep : 1830913320003 :A
IDENTITAS DATA Nama Umur Nama Ayah/lbu Pekerjaan Ayah/Ibu Pendidikan Ayah/Ibu Alamat / No. Telpon Suku Agama Ruangan Diagnosa Medis
:.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :.............................................................................................. :..............................................................................................
II. ALASAN MASUK
……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… III. RIWAYAT PENYAKIT a. Keluhan Utama ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… b. Riwayat Penyakit Sekarang ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… c. Riwayat Penyakit Dahulu ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… d. Riwayat Penyakit Keluarga ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………
IV. DATA FOKUS Inspeksi :……………………………………………………………………………… ……………………………………………………………………………… Palpasi :……………………………………………………………………………… ……………………………………………………………………………… Perkusi :……………………………………………………………………………… ……………………………………………………………………………… Auskultasi:……………………………………………………………………………… ……………………………………………………………………………… V. DATA TAMBAHAN BB =………………………………………………………………………………… TB =………………………………………………………………………………… LK =………………………………………………………………………………… LLA =………………………………………………………………………………… VI. DATA PENUNJANG NCHS a. BB/U ………………………………………………………………………………………… ……...…………………………………………………………………………………... .......................................................................................................................................... .......................................................................................................................................... b. TB/U ………………………………………………………………………………………… ……...…………………………………………………………………………………... .......................................................................................................................................... .......................................................................................................................................... c. BB/TB ………………………………………………………………………………………… ………………………………………………………………………………………….. .......................................................................................................................................... .......................................................................................................................................... d. CDC 2000 ………………………………………………………………………………………… ……..…………………………………………………………………………………... .......................................................................................................................................... ..........................................................................................................................................
VII. ANALISA DATA DATA …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. …………………………………………………. ………………………………………………….
ETIOLOGI ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ……………………….. ………………………..
MASALAH ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ………………………………. ……………………………….
VIII. RENCANA ASKEP 1. Diagnosa Keperawatan :………………………………………………............ ………………………………………………............. ………………………………………………............. 2.
Tujuan
: …………………………………………………………….. ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ………………………………………………………………
3.
Kriteria Hasil
: …………………………………………………………….. ……………………………………………………………… ……………………………………………………………… ………………………………………………………………
4.
Intervensi
: …………………………………………………………….. ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ………………………………………………………………
5.
Implementasi
: …………………………………………………………….. ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ……………………………………………………………… ………………………………………………………………
6.
Evaluasi S
:………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
O
:………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………
A
:………………………………………………………………………………… ………………………………………………………………………………… ………………………………………………………………………………….
P
:………………………………………………………………………………… …………………………………………………………………………………
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