WIDYA MANDALA HOSPITAL

Jl. Kalisari Selatan 1, Pakuwon City Surabaya.

1. THE MAIN COMPLAINT
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Nursing Problem :

2. PAST MEDICAL HISTORY :

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3. CURRENT MEDICAL HISTORY.
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4. FAMILY MEDICAL HISTORY
DM Hypertension basedow

Heart Epilepsy etc

Alergies Cancer

Lupus asthma

5. Genogram
6. History of alergies.
Medicine, reaction : ___________________________________

Food, reaction : ______________________________________

Plester, reaction : _____________________________________

Etc, reaction : ________________________________________

7. Medical devices used during assessment

Infusion

Infusion Pump, IV set Transfusion set

Name of infusion : _______________________
Number of gift : _________________________
Number of droplet : ______________________
Location : ______________________________
Aids Breathing :
Nasal : _________________________________
Simple mask : ___________________________
Mask the reservoir : _______________________
Tracheostomy : __________________________
Ventilator : ______________________________
Folley Chateter or Three way cahteter.
Number : _________________________________
The contents of a bellon : ____________________
The color of urine : _________________________
The amount of urine : _______________________
Naso Gastric Tube (NGT)
Drain
The name of drain : __________________________
Location : __________________________________
Spending : What kind of : Color :
ETC

Nursing problem :
 TINDAKAN KEPERAWATAN

TANGGAL JAM NO. DX TINDAKAN KEPERAWATAN PARAF