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Snoring Gurgling
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Hasil Laboratorium:
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Terapi Medis:
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Nyeri : Ada Tidak Ada
Problem : .......................................................................................................................
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Qualitas/ quantitas : ...................................................................................................................
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Regio : .......................................................................................................................................
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Timing : .....................................................................................................................................
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GIVE COMFORT
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Keluhan utama :
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Mekanisme cidera (trauma) :
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Sign / tanda gejala :
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Alergi :
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Medication / pengobatan :
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Post Medical History :
HISTORY
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Last Oral Intake:
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Event Leading Injury:
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(fokus pemeriksaan pada daerah trauma / sesuai kasus nontrauma )
Kepala dan wajah
Inspeksi :
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Leher
Palpasi :
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Inspeksi :
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Palpasi :
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Dada
Inspeksi :
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HEAD TO TOE
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Palpasi :
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Perkusi :
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Auskultasi :
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Abdomen
Inspeksi :
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Auskultasi :
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Palpasi :
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Perkusi :
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Pelvis dan perineum :
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Ekstremitas :
Atas:
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Bawah
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Masalah keperawatan :
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Crepitasi : Ada Tidak
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Laserasi : Ada Tidak
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