DisusunOleh :
A. Pengkajian
1. Identitas Pasien
a. Nama :
b. Alamat :
c. Umur :
d. Pendidikan :
2. Riwayat Keperawatan
a. Keluhan Utama
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b. Faktor Predisposisi
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c. Faktor Presipitasi
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d. Fisik
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e. Psikososial – Spiritual
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