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FORMAT ASKEP KGDI. PENGKAJIANTanggal Masuk RS:Ruang Pengkajian:Tanggal & Jam Pengkajian:A. Biodata PasienNama:Jenis Kelamin:Usia:Berat Badan:Tinggi Badan:Pendidikan:Pekerjaan:No RM:Diagnosa medis:B. Biodata Penanggung JawabNama: Jenis Kelamin:Pendidikan: Pekerjaan: Hubungan dengan Klien : Alamat:C. Pengkajian PrimerAirways:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Breathing:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Circulation:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Disability:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Exposure:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................D. Pengkajian SekunderS (Sign and Symptoms)........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................A (Allergies)................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................M (Medications)................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................P (Past Illness)........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................L (Last Meal)................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................E (Event)................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................E. Pemeriksaan Fisika. Keadaan umum....................................................................................................................................................................................................................................b. KesadaranTanggal/jam pengkajianTingkat kesadaranRespon mataRespon motorikRespon verbalNilai GCS

c. Vital sign Tanggal/waktupengkajianTekanan DarahHeart RateRRSuhuCapillary refill

d. Kepala 1. Inspeksi................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Palpasi....................................................................................................................................................................................................................................................................................................................................e. Mata 1. Inspeksi................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Palpasi....................................................................................................................................................................................................................................................................................................................................f. Hidung1. Inspeksi................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Palpasi..............................................................