LAPORAN RESUME

ASUHAN KEPERAWATAN
Nama :
NPM :
1. PENGKAJIAN
Identitas
Nama
Umur
Jenis Kelamin
Pekerjaan
Agama
Suku Bangsa
Alamat

Ruangan

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Wawancara
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Pemeriksaan Fisik
a. Penampilan umum pasien
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b. TTV
TD : .......................
N : .......................
S : .......................
P : .........................
c. Kulit
Inspeksi :.......................................................................................................
Palpasi :........................................................................................................
d. Mulut dan faring
Inspeksi :........................................................................................................
.
Palpasi :........................................................................................................
.
e. Abdomen
Inspeksi :........................................................................................................
...
Palpasi
:...........................................................................................................
Auskultasi:........................................................................................................
...
Perkusi :........................................................................................................
....
F. Neurologis
Kesadaran (GCS) :
.
Status mental : ...
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Motorik (kejang, tremor, parese dan
paralisis) : ....................................................
Sensorik :

Tanda rangsang meningeal :

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Saraf kranial :
1. Nervus Olfaktorius :

2. Nervus Optikus :
3. Nervus Okulomotorius :
4. Nervus Troklearis :
5. Nervus Trigeminus :
6. Nervus Abdusen :
7. Nervus Facialis :
8. Nervus Vestibulokoklearis :
9. Nervus Glosofaringeus :
10. Nervus Vagus :
11. Nervus Aksesorius :
12. Nervus Hipoglosus :

Reflek fisiologis :
1. Reflek Bicep :
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2. Reflek Tricep :
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3. Reflek Petela :
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Reflek patologis :
1. Reflek Babinsky :
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2. Reflek Chadock :
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3. Reflek Gordon :
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4. Reflek Schaefer :
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5. Reflek Gonda :
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G. ANALISA DATA
NO

DATA

ETIOLOGI

MASALAH

 Diagnose keperawatan
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Pemeriksaan penunjang
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RENCANA ASUHAN KEPERAWATAN

Nama Klien

Ruang Rawat
Diagnosa Medik :

DIAGNOSA

KEPERAWATAN

TUJUAN

KRITERIA HASIL

INTERVENSI

CATATAN PERKEMBANGAN

Nama klien

Ruang rawat

Diagnosa medik

Hari/tgl

Diagnosa
Keperawatan

Implementasi

Evaluasi

Jam :

Jam :
S:

O:

A:

P:
Tanda tangan
Perawat

Diagnose keperawatan
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 Pemeriksaan penunjang
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