BAPTIS KEDIRI STIKES
STRATA NURSING PRODUCT 1
BASIC NURSING FORM
STUDENT NAME : ……………………………………………………
NIM : ……………………………………………………
SPACE : ……………………………………………………
DATE : ……………………………………………………
1. BIODATA:
Patient's Name : ………………………………………………. ............ .......
Nickname : ………………………………………………. ...........................
Age : ………………………………………………. ............
Status : ………………………………………………. ............
Religion : ……………………………………………….
Education : ………………………………………………. ............
Occupation : ………………………………………………. ............
Earnings : ………………………………………………. ............
Address : ………………………………………………. ............
Medical Diagnosis : ……………………………………………….
MRS Date : ……………………………………………….
Date of Assessment : ……………………………………………….
Blood Type : ………………………………………………. .
2. MAIN COMPLAINTS
3. HISTORY OF DISEASE NOW
4. PAST DISEASE HISTORY
5. FAMILY HEALTH HISTORY
GENOGRAM :
6. VITAL SIGNS
Temperature : ................................. º C
Pulse : …………………………… x / minute
Blood Pressure: …………………………… mmHg
Respiration : …………………………… x / minute
TT / TB : …………………………… Kg, …………… .cm
7. DAILY ACTIVITY PATTERNS
a. Personal Hygiene Needs
b. Nutrition Needs / Nutrition Patterns
c. Needs for Elimination / Elimination Pattern of BAK, BAB
d. Oxygenation Needs
e. Fluid and Electrolyte Needs
f. activity needs
g. The Need for Safety and Comfort
h. Psychosocial and Spiritual needs
8. STATE / APPEARANCE / PUBLIC IMPRESSION
9. PHYSICAL EXAMINATION
A. Head and Neck Examination
B. Pemeriksaan Integumen Kulit dan Kuku :
C. Breast and Underarm Examination (If needed):
D. Chest / Thorak examination
Thorax Inspection:
Lung:
E. Heart Check:
F. Abdomen Examination:
G. Sex Check and surrounding area (if needed):
Geneticist:
Anus :
H. Musculoskeletal examination:
I. Neurology Examination:
J. Mental Status Check:
10. Pemeriksaan Penunjang Medis :
11. Implementation / Therapy:
12. Client / Family Expectations regarding his illness:
Kediri, ............................
College student,
DATA ANALYSIS
PATIENT'S NAME :
AGE :
NO. REGISTER :
SOFT DATA RELATED FACTORS / NURSING (NANDA)
OBJECTIVE DATA RISK (E) PROBLEMS
SUBJECTIVE DATA
NURSING PLANNING
PATIENT'S NAME :
AGE :
NO.REGISTER :
NURSING DIAGNOSIS :
NOC: ................................................ .................................................. .
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
NOC: ................................................ ..................................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
NOC: ................................................ ................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
…………………......... Maintained / enhanced ............................................
Note: (retained / enhanced) strikethrough one
LIST OF NURSING DIAGNOSIS
PATIENT'S NAME :
AGE :
NO. REGISTER :
NO DATE NURSING DIAGNOSES DATE SIGNATURE
APPEAR TERATASI
\ Askep format 201 7
NURSING PLANNING
PATIENT'S NAME :
NO.REGISTER :
NO NURSING DIAGNOSES INTERVENTION RATIONAL TTD
(NIC)
\ Askep format 201 7
NURSING ACTIONS
PATIENT'S NAME :
AGE :
NO.REGISTER :
NO NO.DX TGL/JAM NURSING ACTIONS SIGN
HAND
\ Askep format 201 7
NOTES OF DEVELOPMENT
PATIENT'S NAME:
AGE :
DATE :
NO NO.DX HOUR EVALUATION (SOAP)
\ Askep format 201 7
