ASESMEN PASIEN TAHAP TERMINAL

1. Keluhan
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2. Tanda-tanda Vital : TD : ....... mmHg Nadi : .. x/i RR : .... x/i Suhu : .... C
3. Pemeriksaan fisik
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4. Diagnosa Medis

5. Therapi

6. Respon Therapi

a. Nyeri Tidak Ya, Skala..............

Intervensi
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b. Gejalan seperti : mual/muntah Tidak Ya
c. Kebutuhan psikososial dan emosional pasien dan keluarga
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Intervensi
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d. Kebutuhan spritual/rohaniawan pasien dan keluarga
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Intervensi
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e. Status sosial/budaya hubungan pasien dengan anggota keluarga
Baik/dekat Tidak baik/kurang dekat
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................................. Padang, ......................... Jam : WIB
DPJP/Dokter jaga Perawat yang melakukan pengkajian

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Nama jelas / Tanda Tangan Nama jelas & Tanda Tangan