NURSING CARE

I. Patient’ Identity
Name :
Age :
Sex :
Adress :
Nationality :
Education :
Occupation :
Marital status :
Religion :
Date of Assessment :
Source of Information :
Date of Admission :

II. Patient’s History

1) Patient’s chief complaint on admission :
2) Patient’s current case history :
3) Patient’s past medical case history :
4) Patient’s family medical history :

III. Current Assesment (before and after admission)

1) Perception and health maintenance :
2) Nutritional metabolic pattern :
Food intake

3) Ellimination Pattern :
a. Bowel movement :

b. Bladder :

4) Activity and exercise pattern

Self Care independent Using aid dependen Dependent Dependen

t and using aid on oxygen
Eat/drink
Take a bath
Toileting
Get dress
Bed mobilization
Movement
Body alignmement
and range of
motion
5) Sleeping and Resting Pattern

6) Perceptual Pattern
a. Vision
b. Hearing
c. Taste

7) Stress Management
8) Norma and Believe

DATA ANALYSIS

No Data Etiology Problem

1

NURSING DIAGNOSIS

1) Nyeri bd tekanan darah tinggi

2) Nutrisi

NURSING PLAN

No Diagnosis purpose Intervention Rationale

plan
 1

IMPLEMENTATION

No Date preparation implementation signature

1

EVALUATION

No Date Nursing Evaluation

diagnosis
Subjective Objective analysis planning
1
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