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RM 04.
38
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Tanggal Diagnosa Medis :
SHIFT PAGI SIANG MALAM
SITUATION (S)
Masalah
Keperawatan
BACKGROUND (B)
Keluhan
Hasil Observasi E............... M............... V............... E............... M............... V............... E............... M............... V...............
 GCS/Kesadaran Kanan:................. Kiri:................... Kanan:................. Kiri:................... Kanan:................. Kiri:...................
 Pupil/Reaksi TD:...................... N:...................... TD:...................... N:...................... TD:...................... N:......................
 Tanda-tanda Vital RR:...................... T:...................... RR:...................... T:...................... RR:...................... T:......................
Pain: Tidak Pain: Tidak Pain: Tidak
Ya Skor:.................... Ya Skor:.................... Ya Skor:....................
Lokasi: .......................................... Lokasi: .......................................... Lokasi: ..........................................
Durasi: .......................................... Durasi: .......................................... Durasi: ..........................................
Frekuensi: ..................................... Frekuensi: ..................................... Frekuensi: .....................................
Risiko Dekubitus Braden Skor:....... Dekubitus Braden Skor:....... Dekubitus Braden Skor:.......
Jatuh/cidera Skor: ................ Jatuh/cidera Skor: ................ Jatuh/cidera Skor: ................
Wound Tidak ada Tidak ada Tidak ada
Ada, lokasi: ............................. Ada, lokasi: ............................. Ada, lokasi: .............................
Stage: ..................................... Stage: ..................................... Stage: .....................................
Balutan: Bersih Rembesan Balutan: Bersih Rembesan Balutan: Bersih Rembesan
GV terakhir: .................................. GV terakhir: .................................. GV terakhir: ..................................
...................................................... ...................................................... ......................................................
Tindakan yang O2: ........... l/mnt Metode: ............. O2: ........... l/mnt Metode: ............. O2: ........... l/mnt Metode: .............
sudah dilakukan IV: ................................................. IV: ................................................. IV: .................................................
NGT NGT NGT
Drain, lokasi: .......................... Drain, lokasi: .......................... Drain, lokasi: ..........................
Gula Darah: ............................ Gula Darah: ............................ Gula Darah: ............................
Kateter: ................................... Kateter: ................................... Kateter: ...................................
................................................ ................................................ ................................................
Keseimbangan Eliminasi:................ BAB:.............x Eliminasi:................ BAB:.............x Eliminasi:................ BAB:.............x
Cairan Konsistensi:............ Warna:........... Konsistensi:............ Warna:........... Konsistensi:............ Warna:...........
Intake:.................... Output:........... Intake:.................... Output:........... Intake:.................... Output:...........
Balance:........................................ Balance:........................................ Balance:........................................
Hasil Lab / RO ...................................................... ...................................................... ......................................................
yang Abnormal ...................................................... ...................................................... ......................................................
...................................................... ...................................................... ......................................................
ASSESMENT (A)
Diagnosa
keperawatan
RECOMMENDATION (R)
Posisi Tidur / Miring kiri (...) Miring kanan (...) Miring kiri (...) Miring kanan (...) Miring kiri (...) Miring kanan (...)
Turning schedule Terlentang (...) .....................(...) Terlentang (...) .....................(...) Terlentang (...) .....................(...)
(jam)
Yang masih perlu di
follow up
Nama Perawat /
Paraf ..................................... ..................................... .....................................
(Perawat) (Perawat) (Perawat)
Nama Keluarga/ ..................................... ..................................... .....................................

Paraf (Keluarga) (Keluarga) (Keluarga)

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