Buku Pedoman dan Panduan Profesi Ners

PENGKAJIAN KEPERAWATAN GAWAT DARURAT (DEWASA)

Identitas Klien

Nama : …………………………………………………………….
Usia : …………………………………………………………….
Jenis Kelamin : …………………………………………………………….
Agama : …………………………………………………………….
Alamat : …………………………………………………………….
Tanggal Masuk : …………………………………………………………….
No. MR : …………………………………………………………….
Diagnosa Medis : ……………………………………………………………

Waktu kedatangan : Waktu diperiksa : Tipe kedatangan :

 Ambulans  Polisi
 Sendiri  Kendaraan umum
 lain-lain : .........................

Kecelakaan : Penyakit : Kondisi kedatangan Diantaroleh:

 Ya  Tidak  Ya  tidak  Sadar  Rangsang verbal  Keluarga  Polisi
Tempat & waktu : sejak :  Rangsang nyeri  Tidak sad  Datangsendiri
r  lain-lain : .........................

Informasi di peroleh dari :  pasien  keluarga, nama :__________  orang lain , nama : ________

TRIAGE jam : Kategori triase :  P1  P2  P3 TB : Cm BB : Kg

Keluhan Utama :
Alcohol :  ya  tidak
Drug abuse :  ya  tidak
Perokok :  ya  tidak

Keterangan : .........................................
........................

Status mental :
Jam BP HR (x/min) Resp (x/ SaO2 (%) Temp. ………°C  Sadar penuh
in)  ax  Tidak sadar
 PR  Respon thd verbal
MAP  oral  Respon thd nyeri

Pengkajian Primer
Airway  Paten  Obstruksi parsial  Obstruksi total  Muntah / aspirasi
1. Wheezing ( )
2. Ronkhi ( )
3. Stridor ( )
4. Suara nafas di thoraks (vesikuler)
5. Sumbatan parsial bisa diketahui dari suara nafas,
a. Gurgling ( )
b. Snoring ( )
c. Crowing ( )

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Breathing  Ada  Tidak Suara nafas : Jelas / bersih ____ka/____ki

 Normal  Lambat  Retraksi Ronchi _____ka/____ki
 Dangkal  Cepat  Batuk Wheezeng _____ka/____ki
 Dalam  Stridor Creckels _____ka/____ki
Absent _____ka/____ki
Circulation Nadi :  ada  tidak Jantung
Nadi (-) Resusitasi Jantung Paru Nyeri dada sekarang :
 dilakukan  tidak  ya  tidak
Kualitas :  regular  irregular  Menyebar  tidak menyebar Denyut Jantung
 kuat  lemah  regular  irregular
CRT :  < 2 dtk  > 2 dtk
Kulit Edema :  ya  tidak
 Normal  Lembab  Jaundice Lokasi : ............................................................
 Kering/hangat  Panas  Dingin Lain-lain :
 Pucat  Mottled  Sianosis
Membran mukosa  Kering  Lembab Perkiraan
kehilangan cairan :…………ml
Output urin : …… ml
........... ml 1jam I /1jam II /1jam III
1. Disability Neurologi
2. Drug 1. A : alert (sadar)
3. Defibrilasi/ 2. V : respon terhadap rangsang vokal/verbal
DC shock 3. P : respon terhadap rangsang nyeri (pain)
4. U : unresponsive
Pupil
Ukuran ____ka/____ki Miosis ____ka/___ki Midriasis ____ka/___ki

GCS : ( E / V / M )
Eye/Mata : ( ) (1-4)
Bicara :  normal  cedal  afasia
Verbal : ( ) (1-5)
Motorik : ( ) (1-6)

Drug : ………………………………………

Defibrilasi / DC shock
(Indikasi bila dilakukan) : …………………
Eksposure Focus pada area injury

Buka pakaian penderita (Cegah hipotermia)

Infus
Kateter Urine : Terpasang / tidak
Produksi urine : ............... cc/jam
Warna urine : Kuning jernih / keruh / ada darah / tidak ada darah
Kateter Three way : Terpasang / tidak
NGT : terpasang / tidak
Hasil :
EKG :.....................................................
Laboratorium :

Rongent (RO) : ........................................

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CT scan : .................................................
Pemeriksaan lain : ....................................

Give Comfort Memberi kenyamanan

1. Selimut mencegah Hipotermi :
2. Kehadiran keluarga :

Histori
Pengkajian Sekunder
1. SAMPLE (Sign and Symptoms, Allergy, Medication, Past medical history, last meal, event leading)

2. Metode untuk mengkaji nyeri : P Q R S T

Riwayat Kesehatan Sekarang :

...................................................................................................................................................................................................
...................................................................................................................................................................................................
...................................................................................................................................................................................................
...................................................................................................................................................................................................
...................................................................................................................................................................................................
...............
Riwayat Kesehatan Lalu :
...................................................................................................................................................................................................
...................................................................................................................................................................................................
...................................................................................................................................................................................................
.........
Riwayat Kesehatan Keluarga :
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....
Nyeri :  ada  tidak
Area nyeri :
Luka :  ada  tidak
Lebar : ........... cm Sedalam : ................
Penyebab/pemulihan :
Skala nyeri : (1-10) ( _________ )
Menyebar ke : .............................. Kualitas : Ringan / Sedang / Berat / Sangat Berat
Waktu nyeri :
 Pelan  Tiba-tiba  Tajam  Tumpul
 Pernah nyeri seperti ini sebelumnya
 Kram  Diremas  Lama  Singkat
 Terbakar  Tertusuk  Tertekan  Kolik
 Hilang timbul  Menetap

Head to Toe Assessment

(Focus pada area injury)

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Kepala Bentuk normal / tidak Keadaan rambut dan kulit

Laserasi / jejas Kepala bersih / kotor
grimace

Mata Palpebra odema ( - / - ) Reflex terhadap cahaya ( - / - )

Sclera ikterik ( - / - ) Pupil isocor / Anisocor
Konjungtiva anemis ( - / - )

Hidung Bentuk normal / tidak Pernafasan cuping hidung ( - )

Laserasi / jejas ( - ) Terpasang Nasal Canul / masker / rebreathing /
Epistaksis ( - ) non rebreathing / tidak
Nyeri tekan ( - )
O2 ……. L/mnt
Telinga Bentuk normal / tidak Ada sekresi / tidak
Laserasi / jejas

Mulut Bibir lembab / kering Terpasang OPT / tidak

Lidah kotor / tidak Produksi secret

Leher Deviasi trachea ( - ) Pembesaran kelenjar

JVD ( - ) Tiroid ( ) Thrakeostomi ( )

Thorak Inspeksi Palpasi

Deformitas ( ) Nyeri tekan ( )
Contusio ( ) Krepitasi ( )
Abrasi ( )
Penetrasi ( )
Gerakan paradoksal ( )
Luka bakar ( )
Laserasi ( )
Bengkak ( )

Paru-paru Perkusi paru

Auskultasi ( )
Ronkhi ( )
Wheezing ( )
Rales ( )

Jantung Ictus cordis teraba pada : Suara jantung I dan II

ICS : ….... 4 katup
HR : ….... x/mnt 1. Tricuspid : di ICS ……..
Ada / tidak pembesaran jantung 2. Bicuspid / Mitral : di ICS ….....
3. Aorta : di ICS …….
4. Pulmonal : di ICS …......
Tunggal / ada tambahan
Murmur
Abdomen Abdomen :
 Lembut  Kaku  Distended  Injury  Guarding  Bruising
 Benda menancap  Normal
 Massa  ada  tidak
Turgor kulit :  Baik  Menurun
Bising usus :  ada  tidak
Tenderness :
 Tidak ada  Epigastrik  Rebound

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 RUQ  RLQ  LUQ

Ekstremitas Inspeksi Palpasi

 Bisa menggerakkan semua ekstimitas  Nyeri tekan  Pulsasi  Sensorik
 Deformitas  Contusio  luka bakar  Krepitasi  Motorik
 Restrain  Penetrasi  edema  Fraktur di : ……...................
 laserasi
 abrasi  lain-lain :

Integumen Inspeksi:
Warna : ............................................................
Jaringan parut : ...............................................
Lesi : ................................................................
Vaskularisasi supervicial : ..............................
Palpasi :
Suhu kulit : .......................................................
Tekstur : (halus / kasur)
Mobilitas/turgor : ..............................................
Lesi : ................................................................

Luka Bakar : Tidak ada / ada

Presentasi Luka bakar : .......................

Genitourinary  Normal  Kesulitan BAK  Disuria  Hematuria  Inkontinensia  Urgency

 Tidak mampu BAK

Obstetric &Ginekologi
 Gravid
 Abortus ___________________

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Perdarahan pervagina :  ya  tidak

Vaginal discharge :  ya  tidak
Kontrasepsi : _________________
Menstruasi terakhir : ___________
Lain-lain :

Inspekt Of Back posterior : …………………….......................................................................................................................

Diagram Kode diagram Pemeriksaan diagnostic
A : Abrasi Jam :
B : Bruise  tidak ada
BU : Burn  USG
E : eritema  darah lengkap
L : laserasi  X Ray
P : Ptekie  BUN
PU : Pressure ulcer  MRI
R : Rash  enzim jantung
S : Scar  CT scan
ST: stoma  elektrolit
U : Ulcer  lain-lain
O : other (tato, amputasi,  glukosa
perubahan warna)  tes fungsi hati
 gas darah arteri
 alcohol dalam darah
 HIV serologi
 EKG
 monitor jantung
 oksmetri nadi
 tes kehamilan
 urinalisis
MEDIKASI PROSEDUR
 Orofaringeal airway
 Terapi nasogastrik
 Nasofaringeal airway
 Kateter urin
 Intubasi ETT
 Kateter vena sentral (CVP)
 Terapi oksigen
 Perawatn Ob/Gyn ___________
Terapi nebulizer
 Perawatan orthopedic ________
 CPR
 Terapitrombolitik
 IV fluid
 Perawatan luka
 DC shock lain-lain :

………………, tgl. ............................

Perawat,

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_______________________
NIM :

Lampiran 30
PENGKAJIAN KEPERAWATAN GAWAT DARURAT (PEDIATRI)

Nama Pasien :....................................................................................................................................

Umur Anak :....................................................................................................................................
Jenis Kelamin :....................................................................................................................................
No Rekam Medik :....................................................................................................................................
Diagnosa Medis :....................................................................................................................................
Tgl Pengkajian :....................................................................................................................................
Jam :....................................................................................................................................
Tgl MRS :....................................................................................................................................

Keluhan Utama
..............................................................................................................................................................
..............................................................................................................................................................
...................................................................................................................
Riwayat kejadian
..............................................................................................................................................................
..............................................................................................................................................................
....................................................................................................................
Riwayat penyakit
dahulu ..............................................................................................................................................................
..................................................................................................................................
Riwayat Allergi
..............................................................................................................................................................
..................................................................................................................................
Riwayat Imunisasi ...............................................................................................................................................................
.................................................................................................................................
Keadaan umum : Baik / Sedang / Lemah
Status Nutrisi : BB ........... Kg TB ...........cm Baik / Sedang / Buruk
General Assessment : Pediatric Assesment Triangle
APPEARANCE Mental status : Compos mentis / Delirium / Sopor / Somnolen / Koma / Menangis
Muscle tone : Kuat / Sedang / emah
...............................................................................................................................................
Body position :
...............................................................................................................................................
BREATHING Airway : Paten / Obstruksi
Jelaskan : .............................................................................................................................................
...
RR: ............... x/menit
Pergerakan dada : simetris /asimetri

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Jelaskan : .............................................................................................................................................
..................................................................................................................................................
Penggunaan otot bantu napas : ada / tidak ada
Suara napas : vesikuler /bronkovesikuler / trakea
Suara napas tambahan : Tidak ada / ronchi / rales / stridor / wheezing
Batuk : Tidak ada / ada / produktif / tidak produktif
Irama pernapasan : Reguler /Ireguler
Jelaskan : ............................................................................................................................................
SIRKULASI Akral : Hangat / kering / merah / dingin / basah
Warna Kulit : Sianosis /Jaundice /Pucat /Normal
Jelaskan :...............................................................................................................................
CRT :< 2 Dtk > 2Dtk
Turgor kulit : Baik / Sedang /Jelek
Edema : tidak ada / ada
Jika ada, gambarkan lokasi : ..................................................................................................
Irama jantung : reguler / ireguler
Perdarahan : tidak ada / ada jenis :.................................................................
PENGKAJIAN PER SISTEM
NEUROLOGI Pupil : isokor / anisokor Reflek cahaya : ....../.........
Ukuran Pupil : Normal / Midriasis / pin point / Meiosis / Lain2
Jelaskan : ...............................................................................................................................
Nyeri : Tidak ada / Ada
Jelaskan (PQRST) : ................................................................................................................
................................................................................................................................................
................................................................................................................................................
Reflek Patologi : ....................................................................................................................
...............................................................................................................................................
Gangguan Neurologi lain : ....................................................................................................
...............................................................................................................................................
Masalah Keperawatan :
..................................................................................................................................................................................
...................................................................................................................................................................................
INTEGUMEN
Luka Bakar : tidak ada / ada Presentasi Luka bakar :.......................

ABDOMEN Frekuensi Peristaltik usus : tidak ada / normal / meningkat / menurun

Mual : tidak ada / ada Emesis : ada / tidak ada

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Gangguan Eliminasi : tidak ada / ada

Jelaskan :...............................................................................................................................
Masalah Keperawatan:
..................................................................................................................................................................................
.....................................................................................................................................................................................
……………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………..

PERKEMIHAN Terpasang kateter : tidak / ya, jenis :.....................................................................................

Produksi urin : normal / poliuri / oliguri / anuria (<100cc/hr)
Jelaskan :...............................................................................................................................
Masalah Perkemihan : Ada / Tidak ada
Jelaskan :...............................................................................................................................

Masalah Keperawatan:
..................................................................................................................................................................................
...................................................................................................................................................................................
TINDAKLANJUT KRS / MRS / PP / DOA / OPERASI / PINDAH / LAIN LAIN

PEMERIKSAAN PENUNJANG

Jenis Pemeriksaan
Jam Hasil
Lab / Foto / ECG / lain lain

PEMBERIAN TERAPI

Jam Tindakan/ medikasi Keterangan

PERAWATAN INTENSIF

JAM TD RR HR SUHU CVP SPO2 Input Output Medikasi

ºC (cc (cc) Obat
)

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PEMERIKSAAN LAIN

………………, tgl. ............................

Perawat,

_______________________
NIM :

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Lampiran 31
PENGKAJIAN KEPERAWATAN GAWAT DARURAT (OBSTETRI)

Nama pasien : .................................. Nama suami :..................................

Umur : .................................. Umur :..................................
Suku/bangsa : .................................. Suku/bangsa :..................................
Agama : .................................. Agama :..................................
Pendidikan : .................................. Pendidikan :..................................
Pekerjaan : .................................. Pekerjaan :..................................
Alamat : .................................. Alamat :..................................
Status perkawinan : ..................................

Primary Assesment
A. Keadaan
Umum : .........................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
..................................................................................
Tingkat Kesadaran : Compos mentis / somnolen / stupor / koma
Glasgow Coma Scale (GCS) : E ….... M .......... V ...........
Cara Datang :
Datang sendiri / Dengan alat bantu / Ambulan
Umur Kehamilan :........ minggu
Kontraksi uterus : Ya / Tidak Frekuensi : …. x / menit Durasi : …... Intensitas :.........
Alasan datang :
Merasa akan melahirkan / Perdarahan pervaginam / Prematur ruptur membran / Trauma / Hiperemesis /
Preeklampsi / Hipoaktivitas janin
Mekanisme trauma : …............................................................................................................................
B. Tanda – Tanda Vital
Tekanan darah : …...../......... mmHg Nadi:........ x/menit Pernafasan: …....x/menit
Suhu : …....ºC
Nyeri: Ya / Tidak Skala Nyeri: ….. (0 – 10) Lokasi
nyeri:..............................
Status kesejahteraan janin :
Denyut Jantung Janin : Ya / Tidak Cara Memeriksa : USG / Dopler / Stetoskop
Frekuensi : ….... x/menit Durasi :.............. Intensitas: …..........

Pemeriksaan ABC
1. Jalan Nafas :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
2. Pola Nafas :
.........................................................................................................................................................................
.........................................................................................................................................................................

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.........................................................................................................................................................................
.........................................................................................................................................................................
3. Sirkulasi :
Tekanan darah: …...../......... mmHg Nadi : ...... (reguler/ireguler) Nafas : .......x/menit
Suhu .........ºC
Akral : ............................ Capillary Refill Time (CRT) : …......
Perdarahan : Ya / Tidak
Sumber Perdarahan : .............................................................

Pemeriksaan Sekunder
No Aspek yang Dikaji Temuan
1 Keadaan Umum

2 Riwayat Kesehatan

3 Tanda – Tanda Vital Saturasi oksigen : .....................................

Gerakan Janin: ada / tidak
Kontraksi uterus : …..................................
4 Kepala dan Leher

5 Dada

6 Abdomen

7 Punggung

8 Ekstremitas

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RIWAYAT KEPERAWATAN
A. Riwayat Obstetri
1. Riwayat Menstruasi
Menarche : umur..... tahun Siklus : teratur / tidak
Banyaknya : .............. Lamanya : ............... hari
HPHT : ............... Keluhan : ...............
2. Riwayat Kehamilan, Persalinan, Nifas Yang Lalu
Anak ke Kehamilan Persalinan Komplikasi Nifas Anak
N Th Um Penyu Jeni Penolo Penyu Lasera Infek Perdarah J. B P
o n ur lit s ng lit si si an K B B

3. Genogram

4. Post Partum Sekarang

Riwayat persalinan sekarang : ................................................................................................
Tipe persalinan : Spontan / bantuan ..............................
Lama persalinan :
a. Kala I : ..................... jam
b. Kala II : .................... jam
c. Kala III : .................... jam
d. Kala IV : .................... jam
5. Rencana Perawatan Bayi : ( ) sendiri ( ) orang tua ( ) lain-lain
Kesanggupan dan pengetahuan dalam merawat bayi :
a. Breast care : .........................................
b. Perineal care : .........................................
c. Nutrisi : .........................................
d. Senam nifas : .........................................
e. KB : .........................................
f. Menyusui : .........................................
B. Riwayat Keluarga Berencana
1. Melaksanakan KB : ( ) ya ( ) tidak
2. Bila ya jenis kontrasepsi apa yang digunakan : .......................................................................
3. Sejak kapan menggunakan kontrasepsi : .......................................................................
4. Masalah yang terjadi : .......................................................................
C. Riwayat Kesehatan

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1. Pengobatan yang pernah dialami ibu : ...................................................................................

2. Pengobatan yang didapat : ...................................................................................
3. Riwayat penyakit keluarga
( ) Diabetes mellitus
( ) Penyakit jantung
( ) Hipertensi
( ) Penyakit lainnya : sebutkan .........................................
D. Riwayat Lingkungan
1. Kebersihan : ...................................................................................
2. Bahaya : ...................................................................................
3. Lainnya, sebutkan : ...................................................................................
E. Aspek Psikososial
1. Persepsi ibu setelah
bersalin : .................................................................................................................................................
.................................................................................................................................................................
................
2. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-
hari? ........................................................................................................................................................
.................................................................................................................................................................
.........
Bila ya bagaimana
…….........................................................................................................................................................
3. Harapan yang ibu inginkan setelah
bersalin : .................................................................................................................................................
.................................................................................................................................................................
................
4. Ibu tinggal dengan siapa :
…………..............................................................................................................................................
5. Siapa orang yang terpenting bagi
ibu : .........................................................................................................................................................
........
6. Sikap anggota keluarga terhadap keadaan saat
ini : ..........................................................................................................................................................
.......
7. Kesiapan mental untuk menjadi seorang ibu : ( ) ya ( ) tidak
F. Kebutuhan Dasar Khusus
1. Pola nutrisi
a. Frekwensi makan : ......................................................................................................
b. Nafsu makan : ......................................................................................................
c. Jenis makanan rumah : ......................................................................................................
d. Makanan yang tidak disukai / alergi / pantangan : ................................................................
2. Pola eliminasi
a. B.a.k
Frekwensi : ........................... kali
Warna : .................................
Keluhan : .................................
b. B.a.b
1) Frekwensi :........................... ´ /hari

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2) Warna :.....................................
3) Bau :.....................................
4) Konsistensi :.....................................
5) Keluhan :.....................................
3. Pola personal hygiene
a. Mandi
Frekwensi : .....................................´ /hari Sabun : ( ) ya ( ) tidak
b. Oral hygiene
Frekwensi : .....................................´ /hari
Waktu : ( ) pagi ( ) sore ( ) setelah makan
c. Cuci rambut
Frekwensi : .....................................´ /hari
Shampoo : ( ) ya ( ) tidak
4. Pola istirahat tidur
a. Lama tidur : ................................................................................................
b. Kebiasaan sebelum tidur : ................................................................................................
c. Keluhan : ................................................................................................
5. Pola aktifitas dan latihan
a. Kegiatan dalam pekerjaan : .........................................................................
b. Waktu bekerja : ( ) pagi ( ) sore ( ) malam
c. Olahraga : ( ) ya ( ) tidak
Jenisnya : ................................................................
Frekwensi : ................................................................
d. Kegiatan waktu luang :.................................................................
e. Keluhan dalam aktifitas :..................................................................
6. Pola kebiasaan yang mempengaruhi kesehatan
a. Merokok : ........................................................................................
b. Minuman keras : ........................................................................................
c. Ketergantungan obat : ........................................................................................
G. Pemeriksaan Fisik
Keadaan umum : ..................................
Tekanan darah : .................................. mmHg
Respirasi : .................................. x/m
Berat badan : ............................. kg
Kesadaran : ..................................
Nadi : .................... ´ /menit
Suhu :............................. °C
Tinggi badan :................................ cm
Kepala, mata, kuping, hidung dan tenggorokan :
1. Kepala : Bentuk ..................................................................................................................
2. Keluhan
: ........................................................................................................................................................
Mata :
1. Kelopak mata
: ........................................................................................................................................................
2. Gerakan mata
: ........................................................................................................................................................

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3. Konjungtiva
: ........................................................................................................................................................
4. Sklera
: ........................................................................................................................................................
5. Pupil
: ........................................................................................................................................................
6. Akomodasi
: ........................................................................................................................................................
7. Lainnya, sebutkan
: ........................................................................................................................................................
Hidung :
1. Reaksi alergi
: ........................................................................................................................................................
2. Sinus
: ........................................................................................................................................................
3. Lainnya, sebutkan
: ........................................................................................................................................................
Mulut dan tenggorokan :
1. Gigi
: ........................................................................................................................................................
2. Kesulitan menelan
: ........................................................................................................................................................
3. Lainnya, sebutkan
: ........................................................................................................................................................
Dada dan axilla :
1. Mammae
: ........................................................................................................................................................
2. Areolla mammae
: ........................................................................................................................................................
3. Papilla mammae
: ........................................................................................................................................................
4. Colostrum
: ........................................................................................................................................................
Pernafasan :
1. Jalan nafas
: ........................................................................................................................................................
2. Suara nafas
: ........................................................................................................................................................
3. Menggunakan otot-otot bantu pernafasan :.............................................................
4. Lainnya, sebutkan
: ........................................................................................................................................................
Sirkulasi jantung :
1. Kecepatan denyut apical : .................................................................... ´ /menit
2. Irama
: .........................................................................................................................................
3. Kelainan bunyi jantung
: ........................................................................................................................................

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 Buku Pedoman dan Panduan Profesi Ners

4. Sakit dada
: ........................................................................................................................................
5. Timbul
: . ........................................................................................................................................
6. Lainnya, sebutkan
: ........................................................................................................................................
Abdomen :
1. Mengecil
: ........................................................................................................................................................
2. Linea & striae
: ........................................................................................................................................................
3. Luka bekas operasi
: ........................................................................................................................................................
4. TFU
: ........................................................................................................................................................
5. Kontraksi
: ........................................................................................................................................................
6. Lainnya, sebutkan
: ........................................................................................................................................................
Genitourinary :
1. Perineum
: ........................................................................................................................................................
2. Lokhea
: ........................................................................................................................................................
3. Vesika urinaria
: ........................................................................................................................................................
4. Lainnya, sebutkan
: ........................................................................................................................................................
Ekstremitas (integumen/muskuloskeletal)
1. Turgor kulit
: ........................................................................................................................................................
2. Warna kulit
: ........................................................................................................................................................
3. Kontraktur pada persendian
ekstremitas : ........................................................................................................................
4. Kesulitan dalam pergerakan :
............................................................................................................................................
5. Lainnya, sebutkan
: ........................................................................................................................................................

DATA PENUNJANG
Laboratorium
: ..............................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................

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 Buku Pedoman dan Panduan Profesi Ners

USG
: ........................................................................................................................................................
Rontgen : ..................................................................................................................................
......................
Terapi yang didapat
: ..............................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...................................................................................

DATA TAMBAHAN
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
..................................................................

STIKes Widya Cipta Husada Tahun 2019 18