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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
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Tanggal
Inspeksi
Palpasi
Perkusi
Auskultasi
k. Jantung
Tanggal
Inspeksi
Palpasi
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Perkusi
Auskultasi
l. Abdomen
Tanggal
Inspeksi
Palpasi
Perkusi
Auskultasi
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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)
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G. Terapi
Nama Obat Dosis Rute Indikasi Kontra Indikasi Efek Samping Ttd
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II. ANALISA DATA
NoTanggal/
JamData Problem Etiologi
Diagnosa
Keperawatan
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III. PRIORITAS DIAGNOSA KEPERAWATAN
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IV. RENCANA KEPERAWATAN
NoTanggal/
JamNo. Dx Tujuan Intervensi Ttd
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V. IMPLEMENTASI KEPERAWATAN
NoTanggal/
Jam
No.
DxImplementasi Respon Ttd
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VI. EVALUASI
NoTanggal/
JamDx. Keperawatan Evaluasi
Ttd