Escolar Documentos
Profissional Documentos
Cultura Documentos
1.ANAMNESIS:
1.Keluhan Utama:....................................................................................................................................................................................
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2.Keluhan Tambahan:.............................................................................................................................................................................
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Lain-lain..........................................................................................................................................................................................
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II.PEMERIKSAAN FISIK:
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IV.DIAGNOSIS:
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V.RENCANA KERJA (EDUKASI,TERAPI DAN DIAGNOSTIK):
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VI.TINDAK LANJUT:
Pulang
MRS
Dikonsulkan..........................................................................................
Dirujuk Ke............................................................................................
Alasan......................................................................................................
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I. Asesmen Keperawatan
Tanggal Asesmen : ……………………… Jam Asesmen : ……………………………………………………………………………………………………………….
Data diperoleh dari : Pasien Keluarga
1. Data Awal : a. Keluhan Utama : ……………………………………………………………………………………………………………………………………….
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b. Keadaan Umum : ……………………………………………………..……………………………………………………………………………….
c. Kesadaran : ……………………………………………………………………………………………….……………………………………..
d. TTV : TD : ……mmHg. Nadi : …….x/menit Suhu : …..C. RR:.….x/menit
e. Antropometri : BB : ……Kg
2. Riwayat Penyakit : Tidak ada Ada, Sebutkan ……………………………………………………………………………..………………………………..
3. Riwayat Alergi Obat/Makanan : Tidak Ada Ada, sebutkan ……………………………………………………………..……….…………………
4. Status Sosial Ekonomi : Pekerjaan : PNS TNI/POLRI Pensiun Lainnya…………………………………………………………….
Status Ekonomi : Biaya Sendiri Asuransi/Perusahaan………………………………………….……………………
Agama: Islam Hindu Budha Katolik Kristen Konghucu
Keyakinan/Kepercayaan ……………………………………………………………………………………………….……………………..
5. Status Psikologis : Cemas Takut Marah Sedih Kecenderungan Bunuh Diri Lainnya ………………………………..……
6. Skrining Nyeri : Adakah keluhan nyeri? Tidak Ada Ada Ringan 1-3 Sedang 4-6 Berat 7-10
8. Assesmen Risiko cedera /jatuh berdasarkan Time Up and Go
No Penilaian Ya Tidak
1 Cara berjalan ( salah satu / lebih)
a. Tidak seimbang / sempoyongan / limbung
b. Jalan dengan menggunakan alat bantu ( kruk, tripot, atau di bantu orang lain)
2 Saat akan duduk : tampak memegang pinggiran kursi atau meja atau benda lain sebagai penopang
Beri tanda (a ) yang sesuai dengan kondisi pasien
Hasil : Tidak berisiko (tidak ditemukan nomor 1 dan 2)
Risiko Rendah (ditemukan pada salah satu nomor )
Risiko Tinggi (ditemukan nomor 1 dan 2)
(………………………………..)
Nama jelas dan Tanda Tangan