RESUME

NAMA KLIEN :An.U TANGGAL : 20-11-2017

S O A P I E
- Ibu pasien - An.U terlihat ..Ketidakefe Tujuan : Setelah dilakukan memposisikan pasien untuk
mengatakan lemas ktifan tindakan keperawatan 1 x 30 memaksimalkan ventilasi
S : Ibu pasien mengatakan ana
anaknya, batuk, - S: 37 C bersihan menit bersihan jalan nafas
pasien kembali efektif mengeluarkan secret dengan batuk, pilek sejak 4 hari yang la
pilek sejak 4 hari - N : 100x/menit jalan
batuk
yang lalu - RR : 40x/menit nafas........... Kriteria Hasil : mendapatkan - O: An.U terlihat lemas
................................. ............................. .............. perubahan skor sesuai targer Auskultasi suara nafas, catat S: 37 C
. .......... ................... pada indicator NOC adanya suara nafas tambahan N : 100x/menit
................................. .............................. ................... RR : 40x/menit
NOC : Respiratory status: Monitor nadi, suhu, dan RR
. ......... ...
Airway patency
................................. .............................. ................... Monitor frekuensi pernafasan
. ......... ................... Indikator 1 2 3 4 5 A: Masalah sesuai dengan NOC te
Monitor pola pernafasan
................................. .............................. ...
abnormal sebagian
. ......... ................... Mendemonstras
................................. .............................. ................... P: Intervensi dilanjutkan
ikan batuk
. ......... ...
efektif
................................. .............................. ...................
........................
. ......... ................... Mampu ..............
....................................
................................. .............................. ...
mengidentifikasi ....................................
. ......... ................... .........................................
kan dan ....................................
................................. .............................. ................... .........................................
....................................
. ......... ... mencegah .........................................
....................................
................................. .............................. ................... faktor yang .........................................
....................................
. ......... ................... dapat .........................................
....................................
................................. .............................. ... .........................................
menghambat ....................................
. ......... ................... .........................................
....................................
................................. .............................. ................... jalan nafas ......................................... ....................................
. ......... ... ......................................... ....................................
................................. .............................. ................... Menunjukkan ......................................... ....................................
. ......... ................... jalan nafas ......................................... ....................................
................................. .............................. ... yang paten ......................................... ....................................
. ......... ................... ......................................... ....................................
(tarik nafas
................................. .............................. ................... ......................................... ....................................
dalam, irama
. ......... ... ......................................... ....................................
................................. .............................. ................... nafas, tidak ada ......................................... ....................................
. ......... ................... suara ......................................... ....................................
................................. .............................. ... pernafasan .........................................
. ......... ................... abnormal)
.........................................
................................. .............................. ................... .........................................
. ......... ... .........................................
................................. .............................. ...................
. ......... ...................
................................. .............................. ...
. ......... ...................
................................. .............................. ...................
. ......... ...
................................. .............................. ...................
. ......... ...................
... Intervensi NIC : Airway
Management
...................
................... 1. Posisikan pasien untuk
... memaksimalkan
................... ventilasi
...................
2. Keluarkan secret
...
................... dengan batuk
...................
3. Auskultasi suara nafas,
...
catat adanya suara
................... nafas tambahan
...................
...
...................
NIC: Vital Sign Monitoring
...................
... ............... 1. Monitor nadi, suhu, dan
................... RR
....... ...........
2. Monitor frekuensi
................... pernafasan
...........
3. Monitor pola pernafasan
abnormal

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 ................................
RESUME
NAMA KLIEN :An.A TANGGAL : 20-11-2017

S O A P I E
- Ibu pasien - An.U terlihat ..Ketidakefe Tujuan : Setelah dilakukan memposisikan pasien untuk
mengatakan lemas ktifan tindakan keperawatan 1 x 30 memaksimalkan ventilasi
S : Ibu pasien mengatakan ana
anaknya, batuk, - S: 36,5 C bersihan menit bersihan jalan nafas
pasien kembali efektif mengeluarkan secret dengan batuk, pilek sejak 3 hari yang la
pilek sejak 3 hari - N : 110x/menit jalan
batuk
yang lalu - RR : 45x/menit nafas........... Kriteria Hasil : mendapatkan - O: An.U terlihat lemas
................................. ............................. .............. perubahan skor sesuai targer Auskultasi suara nafas, catat S: 36,5 C
. .......... ................... pada indicator NOC adanya suara nafas tambahan N : 110x/menit
................................. .............................. ................... RR : 45x/menit
NOC : Respiratory status: Airway Monitor nadi, suhu, dan RR
. ......... ...
patency Monitor frekuensi pernafasan
................................. .............................. ...................
. ......... ................... Indikator 1 2 3 4 5 A: Masalah sesuai dengan NOC te
Monitor pola pernafasan
................................. .............................. ...
abnormal sebagian
. ......... ................... Mendemonstras
................................. .............................. ................... P: Intervensi dilanjutkan
ikan batuk
. ......... ...
efektif
................................. .............................. ...................
........................
. ......... ................... ..............
Mampu ....................................
................................. .............................. ...
mengidentifikasi ....................................
. ......... ................... .........................................
kan dan ....................................
................................. .............................. ................... .........................................
....................................
. ......... ... mencegah .........................................
....................................
................................. .............................. ................... faktor yang .........................................
....................................
. ......... ................... .........................................
dapat ....................................
................................. .............................. ... .........................................
menghambat ....................................
. ......... ................... jalan nafas ......................................... ....................................
................................. .............................. ................... ......................................... ....................................
. ......... ... Menunjukkan ......................................... ....................................
................................. .............................. ................... jalan nafas ......................................... ....................................
. ......... ................... yang paten ......................................... ....................................
................................. .............................. ... ......................................... ....................................
(tarik nafas
. ......... ................... ......................................... ....................................
dalam, irama
................................. .............................. ................... ......................................... ....................................
. ......... ... nafas, tidak ada ......................................... ....................................
................................. .............................. ................... suara ......................................... ....................................
. ......... ................... pernafasan ......................................... ....................................
................................. .............................. ... abnormal)
.........................................
. ......... ................... .........................................
................................. .............................. ................... .........................................
. ......... ... .........................................
................................. .............................. ...................
. ......... ...................
................................. .............................. ...
. ......... ...................
................................. .............................. ...................
. ......... ...
................................. .............................. ...................
. ......... ................... Intervensi NIC : Airway
Management
...
................... 4. Posisikan pasien untuk
................... memaksimalkan
... ventilasi
...................
5. Keluarkan secret
...................
... dengan batuk
...................
6. Auskultasi suara nafas,
...................
catat adanya suara
... nafas tambahan
...................
...................
...
NIC: Vital Sign Monitoring
...................
................... 4. Monitor nadi, suhu, dan
... ............... RR
...................
5. Monitor frekuensi
....... ........... pernafasan
...................
........... 6. Monitor pola pernafasan
abnormal

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 ................................
RESUME
NAMA KLIEN :An.M TANGGAL : 21-11-2017

S O A P I E
- Ibu pasien ..Hipertermi Tujuan : Setelah dilakukan Memonitor suhu
mengatakan - S: 38,6 C ................... tindakan keperawatan 1 x 30
Monitor warna dan suhu kulit S : Ibu pasien mengatakan ana
anaknya, demam - N : 115x/menit ...... hipertermi pasien mulai
berkurang demam dan batuk, sejak 4 hari
dan batuk sejak 2 - RR : 45x/menit ................... Monitor nadi dan RR
hari yang lalu ............................. ................... Kriteria Hasil : mendapatkan lalu
Monitor intake dan output
................................. .......... ... perubahan skor sesuai targer - O:
. .............................. ................... pada indicator NOC Berikan pengobatan untuk S: 38,6 C
................................. ......... ................... mengatasi penyebab demam N : 115x/menit
NOC : Thermoregulation
. .............................. ... RR : 45x/menit
Kompres pasien pada lipat paha
................................. ......... ................... Indikator 1 2 3 4 5 dan aksila
. .............................. ...................
................................. ......... ... Suhu tubuh
. .............................. ................... A: Masalah sesuai dengan NOC te
dalam rentang
................................. ......... ................... sebagian
normal
. .............................. ... .............. P: Intervensi dilanjutkan
................................. ......... ...................
Nadi dan RR
. .............................. ................... .........................................
dalam rentang ........................
................................. ......... ... .........................................
. .............................. ................... normal
......................................... ....................................
................................. ......... ................... ......................................... ....................................
Tidak ada ....................................
. .............................. ... .........................................
................................. ......... ................... perubahan
......................................... ....................................
. .............................. ................... warna kulit dan ......................................... ....................................
................................. ......... ... pasien merasa ......................................... ....................................
. .............................. ................... nyaman ......................................... ....................................
................................. ......... ................... ......................................... ....................................
. .............................. ... ......................................... ....................................
................................. ......... ................... ......................................... ....................................
. .............................. ................... ......................................... ....................................
................................. ......... ... ......................................... ....................................
. .............................. ................... ......................................... ....................................
................................. ......... ................... ......................................... ....................................
. .............................. ... ......................................... ....................................
................................. ......... ................... ......................................... ....................................
Intervensi NIC : Fever
. .............................. ................... ......................................... ....................................
threatment
................................. ......... ... ......................................... ....................................
. .............................. ................... 1. Memonitor suhu ......................................... ....................................
................................. ......... ...................
2. Monitor warna dan suhu
. .............................. ...
kulit
................................. ......... ...................
. .............................. ................... 3. Monitor nadi dan RR
................................. ......... ...
4. Monitor intake dan
. .............................. ...................
output
................................. ......... ...................
. .............................. ... 5. Berikan pengobatan
................................. ......... ................... untuk mengatasi
. ................... penyebab demam
...
6. Kompres pasien pada
...................
lipat paha dan aksila
...................
...
...................
.........................................
...................
.........................................
... .........................................
................... .........................................
................... .........................................
... .........................................
................... .........................................
................... .........................................
... ............... .........................................
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....... ........... ........................................
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