II. ANAMNESIS
Keluhan Utama
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Riwayat Penyakit Sekarang
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Riwayat Penyakit Dahulu
Pernah dirawat Tidak Ya, Kapan : ...................... Diagnosa : ......................
Pernah operasi Tidak Ya, Kapan : ...................... Jenis operasi : ......................
Riwayat Penyakit Keluarga
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Riwayat Alergi Tidak Ya
Bahan Alergen : ........................................................... Reaksi yang ditimbulkan : ................................................................
Gelang Alergi Tidak Ya
Psiko-Sosio Spiritual dan Ekonomi
Tinggal bersama : ..............................................................................................................................................
Yang merawat selama di rumah sakit : ..............................................................................................................................................
Yang merawat di rumah : ..............................................................................................................................................
Kegiatan ibadah : ..............................................................................................................................................
Hal yang bertentangan dengan keyakinan : ..............................................................................................................................................
Konsep diri : ..............................................................................................................................................
Hubungan dengan teman dan lingkungan sekitar : ..............................................................................................................................................
Pekerjaan orang tua : ..............................................................................................................................................
Riwayat Imunisasi
DPT I DPT II DPT III BCG MMR HIB Influenza Thypus Varicella
Polio I Polio II Polio III Campak Hepatitis I Hepatitis II Hepatitis III ..................................
Vaksin Ulang Ya Tidak
Tanda - tanda
Vital
Tekanan Darah : ........................ mmHg Frekuensi Nafas : ........................ x/menit BB : ........................ kg
Nadi : ........................ x/menit Saturasi Oksigen : ........................ % TB / PB : ........................ cm
Suhu : ........................ oC Lingkar kepala : ........................ cm
BREATHING (B1)
BRAIN (B3)
BOWEL (B5)
BONE (B6)
ENDOKRIN
PERSONAL HYGIENE
Mandi : ................... x/hr Ganti pakaian : ................... x/hr
Sikat Gigi : ................... x/hr Genetalia Bersih Tidak
Keramas : ................... x/minggu
Memotong kuku : ................... x/minggu
IV. ASESMEN NYERI
Nilai Nyeri / Pain Score
Wong-Baker FACES Pain Rating Scale
Frekuensi Nyeri : Jarang Hilang Timbul Terus menerus
Lama Nyeri : ...........................................................................................
Perawat
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(Nama & Tanda tangan)