I. IDENTITAS
A. Data Pasien
Nama : ......................................................................
Tempat Tanggal Lahir : ......................................................................
Umur : ......................................................................
No. Rekam Medis : ......................................................................
Diagnosis Medis : ......................................................................
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E. Pemeriksaan B1 bearth (Pernafasan)
Frekuensi napas : …………… kedalaman : ……………irama : ……….....
Bunyi Napas: .................................................................................................
Batuk: ............................................................................................................
Pemeriksaan Thorak:
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Intake Nutrisi Sebelum dan Saat Sakit
Makanan
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Minuman
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Nafsu Makan
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2. Optikus Penglihatan
V. OBAT-OBATAN
No Obat Dosis Indikasi
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Keterangan:
Total Skor Intepretasi
16 - 23 Pasien dengan risiko rendah
13 - 15 Pasien dengan risiko sedang
10 - 12 Paasien dengan risiko tinggi
≤9 Pasien dengan risiko sangat tinggi
Tujuan Dan
No. Diagnosa Keperawatan Intervensi Rasional
Kriteria Hasil
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No.
Waktu Waktu Catatan Perkembangan
Dx Tindakan TT TT
Tgl/jam Tgl/jam (SOAP)
Kep
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