FORMAT ASKEP KGD

I. PENGKAJIAN

Tanggal Masuk RS :

Ruang Pengkajian :

Tanggal & Jam Pengkajian :

A. Biodata Pasien

Nama :

Jenis Kelamin :

Usia :

Berat Badan :

Tinggi Badan :

Pendidikan :

Pekerjaan :

No RM :

Diagnosa medis :

B. Biodata Penanggung Jawab

Nama :

Jenis Kelamin :

Pendidikan :

Pekerjaan :

Hubungan dengan Klien :

Alamat :

C. Pengkajian Primer

Airways :

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Breathing :

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Circulation :

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Disability :

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Exposure :

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D. Pengkajian Sekunder

S (Sign and Symptoms)

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A (Allergies)

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M (Medications)

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P (Past Illness)

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L (Last Meal)

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E (Event)

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E. Pemeriksaan Fisik

a. Keadaan umum

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b. Kesadaran

Tanggal/

jam

pengkajian

Tingkat

kesadaran

Respon mata Respon

motori

k

Respon

verbal

Nilai GCS

c. Vital sign

Tanggal/

waktupengkaji

an

Tekanan

Darah

Heart

Rate

RR Suhu Capillary

refill

d. Kepala 1. Inspeksi

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2. Palpasi

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e. Mata

1. Inspeksi

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2. Palpasi

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f. Hidung

1. Inspeksi

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2. Palpasi

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g. Mulut

1. Inspeksi

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2. Palpasi

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h. Telinga

1. Inspeksi

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2. Palpasi

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i. Leher

1. Inspeksi

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2. Palpasi

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j. Paru-paru

Tanggal

Inspeksi

Palpasi

Perkusi

Auskultasi

k. Jantung

Tanggal

Inspeksi

Palpasi

Perkusi

Auskultasi

l. Abdomen

Tanggal

Inspeksi

Palpasi

Perkusi

Auskultasi

m. Genitalia

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n. Ekstremitas atas

1. Sinistra

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2. Dextra

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o. Ekstremitas bawah

1. Sinistra

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2. Dextra

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F. Pemeriksaan Penunjang

Jenis pemeriksaan Hasil Nilai Kesan (meningkat/menurun)

G. Terapi

Nama Obat Dosis Rute Indikasi Kontra Indikasi Efek Samping Ttd

II. ANALISA DATA

NoTanggal/

JamData Problem Etiologi

Diagnosa

Keperawatan

III. PRIORITAS DIAGNOSA KEPERAWATAN

IV. RENCANA KEPERAWATAN

NoTanggal/

JamNo. Dx Tujuan Intervensi Ttd

V. IMPLEMENTASI KEPERAWATAN

NoTanggal/

Jam

No.

DxImplementasi Respon Ttd

VI. EVALUASI

NoTanggal/

JamDx. Keperawatan Evaluasi

Ttd

VII. EVALUASI