Nama mahasiswa :
Tanggal :
NPM :
Tempat :
Nama Pasien :
Diagnosa Medis :
1. Data masalah keperawatan : (data Subyektif, data obyektif dan data penunjang)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
6. Rasional Tindakan
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
7. Evaluasi :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
9. Tindakan keperawatan lainnya yang dapat dilakukan untuk mengatasi masalah tersebut
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Evaluasi Diri
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________