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FORMAT PENGKAJIAN NYERI

Nomor MR :................................ Tanggal Masuk :..............................


Ruangan :................................ Tanggal Pengkajian :..............................
Diagnosa Medis :................................

A. IDENTITAS PASIEN
1. Nama Pasien :
2. Umur :
3. Jenis Kelamin :
4. Pendidikan :
5. Agama :
6. Pekerjaan :
7. Status Perkawinan :
8. Suku :
9. Alamat :
B. PENGKAJIAN NYERI

1. Provocative/palliative
 Apa penyebabnya : .............................................................
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 Hal-hal yang memperbaiki keadaan :............................................................
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2. Quantity/quality
 Bagaimana dirasakan : .............................................................
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 Bagaimana dilihat : ............................................................
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3. Region
 Dimana lokasinya : .............................................................
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 Apakah menyebar : .............................................................
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4. Severity : ...........................................................
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5. Time : .............................................................
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