No.

RM :
ASESMEN PASIEN
Nama :
TAHAP TERMINAL
Tgl. Lhr : Umur:

JK :L/P

1. Pengkajian perawatan dilakukan tanggal.........................Jam..........WIB oleh.........................................

2. Diagnosis.................................................................................................................................................
3. Uraian penyakit / kondisi pasien saat ini :
...................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
4. Riwayat penyakit kondisi sebelumnya :
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
5. Keadaan Umum : Sedang Jelek Sangat jelek

6. Kesadaran : CM Apatis Dellirium Somnolent Soporokoma Koma

7. Tanda – tanda vital :

TD :.................. mmHg Nadi : ..................x/mnt Suhu : .................. °C.
Nafas:............... x/mnt Saturasi O2 : .................. %

8. Skala nyeri : .......................................

9. Tahap pasien waktu menjelang ajal :

Menolak Marah Menawar Depresi Menerima
10. Tanda-tanda klinis menjelang kematian :
Pasien kurang responsif Fungsi tubuh melambat
BAB & BAK tidak sengaja Pernafasan tidak teratur dan dangkal
Rahang cenderung jatuh Ekstrimitas dingin
Nadi cepat dan melemah Sirkulasi menurun
Kulit pucat Mata tidak ada respon cahaya
11. Kebutuhan spiritualitas pasien / keluarga :
....................................................................................................................................................................
.................................................................................................................................................................
....................................................................................................................................................................
12. Daftar masalah keperawatan :
Ansietas / ketakutan individu / keluarga Berduka
Perubahan proses keluarga Resiko Distress Spiritual

Tanggal / Jam selesai pengkajian

........................... / .................WIB

(....................................................)