Nama Pengkaji :

Nim :

Ruangan :

A. PENGKAJIAN

Tanggal :

Hari :

Jam :

I. Identitas pasien

Nama :

Usia :

Jenis Kelamin :

Pendidikan :

Suku Bangsa :

Agama :

Alamat :

Diagnose Medis :

II. Pengkajian Riwayat Kesehatan

1. Keluhan Utama :

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 2. Riwayat Penyakit Sekarang

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3. Riwayat Penyakit Dahulu

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4. Riwayat Penyakit Keluarga

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III. Pengkajian Kritis 6 B

1. Breath (Pernapasan)

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2. Blood (Sirkulasi)

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3. Brain (Persyarafan)

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4. Bladder (Perkemihan)

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5. Bowel (Pencernaan)

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 6. Bone (Muskuloskeletal)

IV. Pengkajian Pola Fungsional

1. Oksigenasi

2. Cairan dan Elektrolit

3. Nutrisi

4. Aman dan Nyaman

5. Eliminasi

6. Aktivitas dan Istirahat

7. Psikososial

8. Komunikasi
 9. Seksual

10. Nilai dan Keyakinan

11. Belajar

V. Pemeriksaan Penunjang

1. Laboratorium
 2. Rongent

3. CT Scan

4. EKG

VI. Terapi