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NURSING ASSESSMENT
Medical History :
Name of Drugs Way to take Frequency Last Time Given
Nursing History
Hearing (Ears) : Clean C Dirty (Ri/Le) C Tinitus (Ri/Le) C Otitis media (Ri/Le)
C
Hearing disorders : C Yes C No Explain :…………….
Pain Assessment
Originator Quality Location/ Scale Time Causes of pain
Radiation (0-10) disappear or decrease
Universal Pain Tool
0 2 4 6 8 10
Not pain Very Mild Moderate Pain Great Pain Very Painful Cannot be
Pain disclosed
Pain Affects :
C Could be ignored C Task C Concentration
C Sleep C Physical Activity C Appetite
Hygien : C clean dirty
C
B4 – Bladder: Perkemihan
C C smelling
Mouth : C Clear Dirty
C C
Mucusa : moist dry. C
Stomatitis
Throat. : C pain swallow Disfagya
enlarge tonsil Etc :
C C
C C
Joint Movement Ability : Independent Limit
C C
: Muscle scale :
C Marah/menangis C Tenang
Surabaya…………………
Dokter Perawat
(…………………………) (…………………………)