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  • Format Resume Keperawatan Medikal Bedah: Identitas

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    Andi Sahputra
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    This document contains a template for a medical and surgical nursing resume. It includes sections for patient identification, chief complaints, medical history, physical examination findings, analysis of examination data including problems identified, and nursing diagnoses. The physical examination section includes assessment of vital signs, general appearance, and examination of head, neck, chest, abdomen, back, extremities, sensory functions and skin among other body systems.

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    This document contains a template for a medical and surgical nursing resume. It includes sections for patient identification, chief complaints, medical history, physical examination findings, analysis of examination data including problems identified, and nursing diagnoses. The physical examination section includes assessment of vital signs, general appearance, and examination of head, neck, chest, abdomen, back, extremities, sensory functions and skin among other body systems.

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    16 views8 pages

    Format Resume Keperawatan Medikal Bedah: Identitas

    Uploaded by

    Andi Sahputra
    This document contains a template for a medical and surgical nursing resume. It includes sections for patient identification, chief complaints, medical history, physical examination findings, analysis of examination data including problems identified, and nursing diagnoses. The physical examination section includes assessment of vital signs, general appearance, and examination of head, neck, chest, abdomen, back, extremities, sensory functions and skin among other body systems.

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    of 8

    FORMAT RESUME KEPERAWATAN MEDIKAL BEDAH

    Tanggal MRS : Jam Masuk :


    Tanggal Pengkajian : No. RM :
    Jam Pengkajian : Diagnosa Masuk :

    IDENTITAS
    1. Nama Pasien :
    2. Umur :
    3. Suku/ Bangsa :
    4. Agama :
    5. Pendidikan :
    6. Pekerjaan :
    7. Alamat :
    8. Sumber Biaya :

    KELUHAN UTAMA

    …………………………………………………………………………………………………………………
    …………………………………………………………………………………………………………………
    …………………………………………………………………………………………………………............

    RIWAYAT PENYAKIT SEKARANG

    Riwayat Penyakit Sekarang:


    ………………………………………………………………………………........................................................
    ……………………………………………………………………………………………………………............
    ................................................................................................................................................................................

    PEMERIKSAAN FISIK

    1. Keadaan Umum
    ………………………………………………………………………………...............................................
    ……………………………………………………………………………………………………………...
    .......................................................................................................................................................................

    2. Pemeriksaan Tanda-tanda Vital

    TD :
    HR :
    RR :
    SUHU :
    3. Pemeriksaan Wajah
    Inspeksi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...
    Palpasi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...

    4. Pemeriksaan Kepala Dan Leher


    Inspeksi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...
    Palpasi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...

    5. Pemeriksaan Thoraks/dada
    Inspeksi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...
    Palpasi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...
    Perkusi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...
    Auskultasi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...

    6. Pemeriksaan Abdomen
    Inspeksi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...
    Palpasi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...
    Perkusi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...
    Auskultasi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...

    7. Pemeriksaan Genetalia dan Rektal


    Inspeksi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...
    Palpasi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...

    8. Pemeriksaan Punggung Dan Tulang Belakang


    Inspeksi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...
    Palpasi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...
    Perkusi:
    ……………………………………………………………………………………………………………...
    ……………………………………………………………………………………………………………...

    9. Pemeriksaan Ektremitas/Muskuloskeletal
    Inspeksi:
    …………………………………………………………………………………………………………......
    ……………………………………………………………………………………………………………...
    Palpasi:
    ………………………………………………………………………………………………………..........
    ……………………………………………………………………………………………………………...

    10. Pemeriksaan Fungsi Pendengaran / Penghidu / tengorokan


    Inspeksi:
    ……………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………
    Palpasi:
    ……………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………

    11. Pemeriksaan Fungsi Penglihatan


    Inspeksi:
    ……………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………
    Palpasi:
    ……………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………

    12. Pemeriksaan Fungsi Neurologis


    Inspeksi:
    ……………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………
    Palpasi:
    ……………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………
    Perkusi:
    ……………………………………………………………………………………………………………
    13. Pemeriksaan Kulit/Integument
    Inspeksi:
    ……………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………
    Palpasi:
    ……………………………………………………………………………………………………………
    ……………………………………………………………………………………………………………

    14. Pemeriksaan Penunjang/Diagnostik Medik


    …………………………………………………………………………………………
    …………………………………………………………………………………………
    …………………………………………………………………………………………

    15. Tindakan Dan Terapi


    …………………………………………………………………………………………
    …………………………………………………………………………………………
    …………………………………………………………………………………………
    ANALISIS DATA

    MASALAH
    NO DATA ETIOLOGI
    KEPERAWATAN
    1 DS:

    DO:

    2 DS:

    DO:

    DIAGNOSA KEPERAWATAN :
    1. ……………………………………………………………………………….................................................
    …………………………………………………………………………………………………......................
    ..........................................................................................................................................................................
    2. …………………………………………………………………………………………………………….....
    .........................................................................................................................................................................
    .........................................................................................................................................................................
    RENCANA INTERVENSI KEPERAWATAN

    NOC NIC
    No. Hari/ Tgl/ Jam DIAGNOSA KEPERAWATAN
    (Nursing Outcome Classification) (Nursing Intervention Classification)
    IMPLEMENTASI DAN EVALUASI KEPERAWATAN

    Hari/Tgl/ No.
    Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
    Shift Dx

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