OLEH:
NI MADE RAI SITA YANTI
1902621040
1. Identitas pasien
Nama : …………………………………………………….
No RM : …………………………………………………….
Umur : …………………………………………………….
Pendidikan : …………………………………………………….
Pekerjaan : …………………………………………………….
Dx Medis : …………………………………………………….
Sistem Kardiovaskuler :
Nyeri dada Ya Tidak
Palpitasi Ya Tidak
CRT < 3 dtk > 3 dtk
Inspeksi:
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Palpasi:
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Perkusi:
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Auskultasi:
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Sistem Respirasi :
Batuk: Ya Tidak
Sesak: Ya Tidak
Inspeksi:
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Palpasi:
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Perkusi:
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Auskultasi:
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Sistem Neurologi :
GCS: Eye: Verbal: Motorik:
Rangsangan meningeal Kaku kuduk Kernig
Brudzinski I Brudzinski II
Nilai
Hari/tanggal Parameter Satuan Hasil Intepretasi
rujukan
B. Diagnosa Keperawatan
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C. Perencanaan
Rencana Keperawatan
No
Hari/tgl
Dx Tujuan dan kriteria hasil Intervensi Rasional
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