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					                         PROGRAM STUDI ILMU KEPERAWATAN FK UGM
                           FORMAT RESUME ASUHAN KEPERAWATAN
                              KEPERAWATAN MEDIKAL BEDAH

Nama mahasiswa                  : Sri Sugesti W. (03/172573/EIK/00353)
Tempat praktek                  : ……………………………………
Tanggal                         : ……………………………………

I.   Identitas diri klien
     Nama                 :............................................   Suku                :……………………………..
     Umur                 : ...........................................   Pendidikan          :..............................................
     Jemis kelamin        :............................................   Pekerjaan           :.............................................
     Alamat               :............................................   Lama bekerja        :..............................................
     ………………………………………………......
     …………………………………………………..                                                Tanggal masuk RS:..........................................
     Status perkawinan :............................................      Tanggal pengkajian:……………………….....
     Agama                :……………………………                                    Sumber Informasi:……………………………

II. Riwayat penyakit
    1. Keluhan utama saat masuk RS:
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    2. Riwayat penyakit sekarang:
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     3. Riwayat Penyakit Dahulu
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     4. Diagnosa medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah dilakukan:
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III. Pengkajian saat ini (mulai hari pertama saudara merawat klien)
     1. Persepsi dan pemeliharaan kesehatan
        Pengetahuan tentang penyakit/perawatan………………………………………………………...
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     2. Pola nutrisi/metabolic
        Program diit RS:………………………………………………………………………………….
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        Intake makanan:…………………………………………………………………………………..
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        Intake cairan:
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     3. Pola eliminasi
        a. Buang air besar
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   b. Buang air kecil
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4. Pola aktifitas dan latihan:

   Kemampuan perawatan diri                            0           1          2           3           4
   Makan/minum
   Mandi
   Toileting
   Berpakaian
   Mobilitas di tempat tidur
   Berpindah
   Ambulasi/ROM
  0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total
  Oksigenasi…..…………………………………………………………………………..……......
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5. Pola tidur dan istirahat
   (lama tidur, gangguan tidur, perawasan saat bangun tidur)
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6. Pola persepsual
   (penglihatan, pendengaran, pengecap, sensasi):
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7. Pola persepsi diri
   (pandangan klien tentang sakitnya, kecemasan, konsep diri)
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8. Pola seksualitas dan reproduksi
   ( fertilitas, libido, menstuasi, kontrasepsi, dll.)
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    9. Pola peran hubungan
        (komunikasi, hubungan dengan orang lain, kemampuan keuangan):
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    10. Pola managemen koping-stess
        (perubahan terbesar dalam hidup pada akhir-akhir ini):
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    11. Sistem nilai dan keyakinan
        (pandangan klien tentang agama, kegiatan keagamaan, dll)
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IV. Pemeriksaan fisik
    (cephalocaudal)
    keluhan yang dirasakan saat ini……………………………………………………………………….
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                                                                         o
    TD:          mm/H           P:      x/m            N:      x/m    S:   C
    BB/TB………………………………………………………………………………………………...
    Kepala………………………………………………………………………………………………...
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    Leher……………………………………………………………………………………………….....
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    Thorak………………………………………………………………………………………………...
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    Abdomen……………………………………………………………………………………………...
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    Inguinal……………………………………………………………………………………………….
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    Ekstrimitas (termasuk keadaan kulit, kekuatan)
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Program terapi:
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Hasil Pemeriksaan Penunjang dan Laboratorium
(dimulai saat anda mengambil sebagai kasus kelolaan, cantumkan tanggal pemeriksaan, dan
kesimpulan hasilnya)
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