Professional Documents
Culture Documents
Nama Mahasiswa
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NIM
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IDENTITAS
1. Nama Pasien :
2. Umur
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3. Gol. Darah :
4. Suku/ Bangsa
5. Agama
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6. Pendidikan :
7. Pekerjaan
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8. Alamat
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9. Sumber Biaya
Jam Masuk :
No. RM
Diagnosa Medis
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KELUHAN UTAMA
Keluhan utama :
Somnolen
Sopor
Koma
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STIKes Surya Mitra Husada Kediri
DATA
ETIOLOGI
MASALAH
KEPERAWATAN
Hari/
Tgl/ Jam
DIAGNOSA KEPERAWATAN
NOC
(Nursing Outcome Classification)
NIC
(Nursing Intervention Classification)
No.
Dx
Jam
Implementasi
Paraf
Jam
Evaluasi (SOAP)
Paraf
PERSIAPAN ALAT
Alat streril
Jumlah
Pre op. Post op.
Jumlah
Pre op. Post op.
b. Habis Pakai
PELAKSANAAN OPERASI :
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EVALUASI
Keadaan Umum :
a. Kesadaran
:
b. GCS
:
Compos Mentis
Apatis
Somnolen
Sopor
Koma
Tekanan darah
(mmHg)
Nadi (kali/menit)
Respiratori rate
(kali/menit)
Suhu (0C)
Balance Cairan :
Menit Ke-
Intake
Jumlah (cc)
Output
Jumlah (cc)
Total
Tanggal : .
Mahasiswa
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