2. Riwayat Keperawatan
a. Riwayat Penyakit Sekarang
d. Personal Hygiene
e. Istirahat
f. Tidur
g. Cairan
h. Nutrisi
i. Kebutuhan oksigenasi dan karbondioksida pernafasan.
j. Kardiovaskuler
k. Seksualitas
b. Hubungan Sosial:
c. piritual.
5. PEMERIKSAAN FISIK
a. Keadaan Umum
1) Kesadaran : GCS:
2) Kondisi secara umum :
3) TTV :
4) Pertumbuhan fisik : TB: BB: postur tubuh:
5) Keadaan kulit :
b. Pemeriksaan Cepalokaudal
1) Kepala :
a) Rambut :
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b) Mata :
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c) Telinga :
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d) Hidung :
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e) Mulut :
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2) Leher
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3) Dada
a) Inspeksi :
____________________________________________________________
____________________________________________________________
b) Auskultasi :
____________________________________________________________
____________________________________________________________
c) Perkusi :
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d) Palpasi :
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4) Abdomen
e) Inspeksi :
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f) Auskultasi :
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g) Perkusi :
____________________________________________________________
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h) Palpasi :
____________________________________________________________
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6. PEMERIKSAAN PENUNJANG
7. TERAPI YANGDIBERIKAN
DAFTAR MASALAH
Tanggal /
NO Data fokus Masalah Keperawatan
jam
INTERVENSI KEPERAWATAN
Tanggal / Diagnosa Standar Luaran Standar Intervensi
No TTD
jam Keperawatan Kperawatan Keperatan