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BIDANG KEDOKTERAN DAN

KESEHATAN
RUMKIT BHAYANGKARA TINGKAT III
ANTON SOEDJARWO PONTIANAK

FORMAT ASESMEN NYERI LANJUTAN

Bila intensitas nyeri 4 dilanjutkan dengan melakukan tatalaksana nyeri :

1. Lokasi dan penyebaran nyeri


: ....................................................................................................................
..........................................................................................................................
..............................

2. Kualitas dan atau penjalaran / penyebaran nyeri


: ....................................................................................................................
..........................................................................................................................
..............................

3. Waktu, durasi dan faktor pemicu nyeri


: ...................................................................................................................
..........................................................................................................................
...............................

4. Faktor yang memperberat dan yang meringankan


nyeri : ...............................................................................................................
..........................................................................................................................
...................................

5. Pengaruh nyeri terhadap aktivitas sehari-hari


: ....................................................................................................................
..........................................................................................................................
..............................

6. Riwayat penanganan nyeri sebelumnya dan efektivitasnya :


..........................................................................................................................
..........................................................................................................................
........................

7. Gejala lain yang menyertai


: ....................................................................................................................
..........................................................................................................................
..............................

Pontianak,..............................
...

Petugas yang mengkaji

(.............................................
.)

Tanda tangan & nama


jelas

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