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DATA KLIEN
A. DATA UMUM
1. Nama inisial klien
2. Umur
3. Alamat
4. Agama
5. Tanggal masuk RS/RB
6. Nomor Rekam Medis
7. Bangsal
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B. PENGKAJIAN PRIMER:
1. Airway (jalan nafas)
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2. Breathing
a. Inspeksi (bentuk dada/simetris, pola nafas, bantuan nafas, dll)
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b. Palpasi (total fremitus, dll)
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c. Perkusi (pembesaran paru, dll)
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d. Auskultasi (suara nafas)
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3. Circulation
a. Vital sign:
1) Tekanan darah :
2) Nadi
:
3) Suhu
:
4) Respirasi
:
b. Capilarry refill
:
c. Akral
:
4. Disability
a. GCS
E: .....
M: ........
b. Pupil
:
c. Gangguan motorik :
V: ......
d. Gangguan sensorik :
Tanggal/Jam
Subjektif
Objektif
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Assessment
(Laboratorium Dan
Therapy)
Plan
Implementasi
Evaluasi
Tujuan:
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Kriteria Hasil (NOC):
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Intervensi (NIC):
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S:.
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O:.
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A:.
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P:.
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