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ASUHAN KEPERAWATAN LONG CASE & MINI CEX

RUMAH SAKIT UMUM DAERAH ULIN BANJARMASIN


DI RUANG DAHLIA (PARU)

Nama Mahasiswa : Nahdiah, S. Kep


NPM : 1614901210744 CI CT
Ruang : Dahlia (Paru)

Nama Klien : ......................................................................


Umur/ tgl lahir : ......................................................................
Diagnosa Medis : ......................................................................
Tanggal Pengkajian : Jum’at, 19 Januari 2018
Riwayat keluahan saat pengkajian : ......................................................................
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DATA FOKUS:
a. Data Subjektif
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b. Data Objektif
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 Inspeksi
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 Palpasi
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 Perkusi
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 Auskultasi
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ANALISA DATA :
DATA PROBLEM ETIOLOGI
Data Subjektif:
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Data Objektif:
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PROSES ASUHAN KEPERAWATAN (INTERVENSI, IMPLEMENTASI DAN EVALUASI)
Diagnosa
NOC NIC Implementasi Evaluasi
Keperawatan
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