I. IDENTITAS
1. Nama : .....................................................................................................................
2. Umur : .....................................................................................................................
3. Jenis kelamin : .....................................................................................................................
4. Status : .....................................................................................................................
5. Agama : .....................................................................................................................
6. Suku/bangsa : .....................................................................................................................
7. Bahasa : .....................................................................................................................
8. Pendidikan : .....................................................................................................................
9. Pekerjaan : .....................................................................................................................
10. Alamat dan no. telp : .....................................................................................................................
11. Penanggung jawab : .....................................................................................................................
6. Riwayat alergi :
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
b. Kebersihan diri
Di rumah Di rumah sakit
Mandi : ........................ /hr Mandi : ........................ /hr
Gosok gigi : ........................ /hr Gosok gigi : ........................ /hr
Keramas : .................... /mgg Keramas : .................... /mgg
Potong kuku : .................... /mgg Potong kuku : .................... /mgg
c. Aktivitas sehari-hari
...................................................................................................................................................
d. Rekreasi
...................................................................................................................................................
e. Olahraga : ( ) tidak ( ) ya
...................................................................................................................................................
b. Pola minum
Di rumah Di rumah sakit
Frekuensi : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Jumlah : ......................... Jumlah : ..................................
Pantangan : .........................
Minuman disukai : .........................
5. Pola Eliminasi
a. Buang air besar
Di rumah Di rumah sakit
Frekuensi : .................................. Frekuensi : ..................................
Konsistensi : .................................. Konsistensi : ..................................
Warna : .................................. Warna : ( ) kuning
( ) bercampur darah
( ) lainnya, ..............
Masalah di RS : ( ) konstipasi ( ) diare ( ) inkontinen
Kolostomi : ( ) tidak ( ) ya
8. Pola Koping
Masalah utama selama MRS (penyakit, biaya, perawatan diri)
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
Kehilangan perubahan yang terjadi sebelumnya
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
Kemampuan adaptasi
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
8. Sistem Integumen
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
9. Sistem Penginderaan
Mata
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
Hidung
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
Telinga
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
VI. TERAPI
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................