Laporan Resume Asuhan Keperawatan.docx

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LAPORAN RESUME ASUHAN KEPERAWATAN

Resume Asuhan Keperawatan Tanggal………………. A. Identitas Pasien Nama

:

No. RM

:

Umur

:

Tgl. MRS

:

Jenis Kelamin

:

Dx. Medis :

Alamat

:

B. Data Fokus S : (Data Subyektif Pasien) “………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………” O : (Data Obyektif Pasien) “……………………………………................................................................................. ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... .........................................................................................................................................”

A : (Assesment) “…………………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………………………………………………………………………”

P : Rencana Keperawatan pada hari itu diperlukan untuk mengisi diagnose pada point A “……………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… ……………………………………………………………………………………………” I : Implementasi yang dilakukan pada hari itu “……………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… ……………………………………………………………………………………………”

E. Evaluasi hari itu untuk masalah pada point A 







S : …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… O: …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………... A: …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… P : …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… ……………………………………………………………………………………

Mengetahui

Ns, IGA Ratih Agustini, S.Kep, M.Kes

Mahasiswa

Ni Kadek Arini, S.Kep

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