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RESUME LAPORAN ASUHAN KEPERAWATAN

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RESUME LAPORAN ASUHAN KEPERAWATAN
ASUHAN KEPERAWATAN PADA ........................................
DENGAN DIAGNOSA MEDIS ...........................................................
DENGAN DIAGNOSA KEPERAWATAN..........................................
DI RUANG …………………..
TANGGAL………………………………………………………………………
…
 PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama
Umur
Agama
Jenis Kelamin
Status
Pendidikan
Pekerjaan
Suku Bangsa
Alamat
Tanggal Masuk
Tanggal Pengkajian
No. Register
Diagnosa Medis
: ..................................................................................
: ..................................................................................
: ....................................................................................
:......................................................................................
: ...........................................................................................
:............................................................................................
: ............................................................................................
:............................................................................................
: ..........................................................................................
: ...........................................................................................
: ...........................................................................................
: .............................................................................................
: ............................................................................................
b. Identitas Penanggung Jawab
Nama
:
............................................................................................
Umur
:
.............................................................................................
Hub. Dengan Pasien : ...........................................................................................
Pekerjaan
: .............................................................................................
Alamat
: ..............................................................................................
2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
Saat MRS :..........................................................................................................
Saat ini : ..........................................................................................................
2) Upaya yang dilakukan untuk mengatasinya
...........................................................................................................................
b. Satus Kesehatan Masa Lalu
1) Penyakit yang pernah dialami
...........................................................................................................................
Pernah dirawat
...........................................................................................................................
Alergi
...........................................................................................................................
2) Kebiasaan (merokok/kopi/alkohol dll)
...........................................................................................................................
3) Riwayat Penyakit Keluarga
...........................................................................................................................
4) Diagnosa Medis dan therapy
...........................................................................................................................
....................................................................................................................................
Data Subyektif: ………………………….
Data Objektif: ……………………………….
Masalah Keperawatan:
Intervensi :……
Evaluasi:
S
O
A
P
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