PROGRAM PENDIDIKAN PROFESI NERS STIKES WIDYAGAMA HUSADA

FORMAT PENGKAJIAN RESUME KASUS KELOLAAN HARIAN

KEPERAWATAN MEDIKAL BEDAH
Nama Mahasiswa

NIM

Tempat Pengkajian

Tanggal

Identitas Klien
Nama
Umur
Jenis Kelamin
Agama
Pendidikan
Alamat

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No. RM
Pekerjaan
Status Perkawinan
Tanggal MRS
Tanggal Pengkajian
Sumber Informasi

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Diagnosa Medis
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Proses keperawatan

a; Pre operasi ( Ruang persiapan operasi)

1; Data focus
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2; Diagnosa keperawatan
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3; Evaluasi
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b; Intra operasi (Ruang Operasi)

1; Data Fokus
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2; Diagnosa keperawatan
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3; Intervensi /Implementasi
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4; Evaluasi
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c; Post operasi (Recovery Room)

1; Data Fokus
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2; Diagnosa keperawatan
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3; Intervensi /Implementasi
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4; Evaluasi
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Probolinggo,
Pengambil Data