NAMA --------------------
NIM...........
2. Riwayat Keperawatan
a. Riwayat Penyakit Sekarang
EliminasiUrine:
d. Personal Hygiene
e. Istirahat
f. Tidur
g. Cairan
h. Nutrisi
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 :
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b) Auskultasi :
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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
ANALISA DATA
Masalah
NO Data Etiologi
Keperawatan
RENCANA KEPERAWATAN
Diagnosa
No Tujuan (SLKI) Intervensi (SIKI)
Keperawatan
TINDAKAN KEPERAWATAN DAN PERKEMBANGAN
Tanggal / Kode Diagnosa Tindakan Keperawatan dan
EVALUASI TTD
jam Keperawatan Respon/Hasil
DIAGNOSA KEPERAWATAN
N DIAGNOSA KEPERAWATAN TANGGAL MASALAH PARAF
O MUNCUL TERATASI