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FORMAT LAPORAN ASUHAN KEPERAWATAN BERDASARKAN FORMAT GORDON



ASUHAN KEPERAWATAN PADA ........................................ DENGAN DIAGNOSA MEDIS ........................................................... DI ............................................................................................... TANGGAL…………………………………………………………………………



I.



PENGKAJIAN 1. Identitas 1. Identitas Pasien Nama



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



Umur



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



Agama



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



Jenis Kelamin



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



Status



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



Pendidikan



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



Pekerjaan



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



Suku Bangsa



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



Alamat



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



Tanggal Masuk



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



Tanggal Pengkajian : ........................................................................................... No. Register



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



Diagnosa Medis



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



2. Identitas Penanggung Jawab Nama : ............................................................................................ Umur



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



Hub. Dengan Pasien



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



Pekerjaan



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



Alamat



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



2. Status Kesehatan 1. Status Kesehatan Saat Ini 1. Keluhan Utama (Saat MRS dan saat ini) ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... 2. Alasan masuk rumah sakit dan perjalanan penyakit saat ini ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... 3. Upaya yang dilakukan untuk mengatasinya ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... 2. Satus Kesehatan Masa Lalu 1. Penyakit yang pernah dialami ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... 2. Pernah dirawat ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... 3. Alergi ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... .....................................................................................................................................................



4. Kebiasaan (merokok/kopi/alkohol dll) ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... 3. Riwayat Penyakit Keluarga ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... 4. Diagnosa Medis dan therapy ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................ ........................................................................................................................................................



3. Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual) a. Pola Persepsi dan Manajemen Kesehatan .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. b. Pola Nutrisi-Metabolik  Sebelum sakit



:



.................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. ..................................................................................................................................................  Saat sakit



:



.................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. c. Pola Eliminasi 1) BAB  Sebelum sakit



:



.................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. ..................................................................................................................................................  Saat sakit



:



.................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. 2) BAK  Sebelum sakit



:



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



 Saat sakit



:



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



d. Pola aktivitas dan latihan 1) Aktivitas Kemampuan



0



1



2



3



4



Perawatan Diri Makan dan minum Mandi Toileting Berpakaian Berpindah 0: mandiri, 1: Alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total



2) Latihan  Sebelum sakit .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... ..........................................................................................................................................  Saat sakit .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... e. Pola kognitif dan Persepsi ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................



f.



Pola Persepsi-Konsep diri ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ..............................................................................................................................................



g. Pola Tidur dan Istirahat  Sebelum sakit



:



.................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................  Saat sakit



:



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



h. Pola Peran-Hubungan .................................................................................................................................................. .................................................................................................................................................. .................................................................................................................................................. ..............................................................................................................................................



i.



Pola Seksual-Reproduksi  Sebelum sakit



:



............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................  Saat sakit



:



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



.............................................................................................................................................. .............................................................................................................................................. j.



Pola Toleransi Stress-Koping ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................



k. Pola Nilai-Kepercayaan ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................



4.



Pengkajian Fisik a. Keadaan umum : Lemas………………………. Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma GCS



: verbal:…5…….Psikomotor:…6…….Mata :……4………..



b. Tanda-tanda Vital : Nadi = …84x/menit……



, Suhu =……36,2oC……. ,



TD =……180/100mmHg……, RR =…22x/menit…… c. Keadaan fisik a. Kepala : Kulit kepala : bersih, warnarambut merata Rambut : rambut berwarna hitam Nyeri tekan : tidak ada nyeri tekan Luka : tidak adanya bekas luka ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ...................................................................................................................................... ....................................................................................................................................... b. Mata : Inspeksi : reflek pupil baik, konjungtiva pucat, slera berwarna putih Palpasi : otot mata dalam keadaan baik ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................



c. Hidung : Inspeksi



: tidak ada secret, tidak adanya edema, tidak adanya lesi, tidak adanya pendarahan dibagian hidung Palpasi : tidak adanya nyeri tekan ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ d. Telinga : Inspeksi : telinga dalam keadaan bersih, tidak ada gangguan bentuk telinga, telinga kanan dan kiri simetris ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ e. Mulut : Inspeksi : tidak adanya pembengkakan, tidak adanya sianosis, bibir tidak ada sariawan, tidak pecah-pecah, warna bibir pucat ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ f. Leher : Inspeksi : tidak adanya benjolan, tidak adanya lesi, tidak adanya kelenjar tiroid Palpasi : adanya nyer tekan pada leher bagian belakang ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ....................................................................................................................................... g. Dada :  Paru Inspeksi : bentuk dada simetris antara kanan dan kiri, gerakan paru simetris antara dextra dan sinistra, tidak adanya benjolan, tidak adanya luka Palpasi : gerakan dada saat ditekan antara kanan dan kiri simetris, vocal premitus teraba, kulit elastis, tidak ada nyeri tekan Perkusi : suara paru sonor Auskultasi : suara paru branchovesikuler ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... .....................................................................................................................................



 Jantung Inspeksi



: bentuk dada kanan dan kiri simetris, tidak adanya benjolan, tidak adanya cekungan, tampak adanya iktus cordis Palpasi : adanya thrill atau getaran pada area iktus cordis Perkusi : terdengar suara dullnes Auskultasi : terdengar suara S1, S2 tunggal reguler (lup dup) ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... ....................................................................................................................................



h. Payudara dan ketiak : Inspeksi : tidak adanya luka Palpasi : tidak terabanya benjolan, tidak ada nyeri tekan ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ i.



abdomen Inspeksi



: : antara perut bagian kanan dan kiri simetris, tidak adanya kontraksi otot, tidak terlihat sianosis Auskultasi : bising usus terdengar Perkusi : suara timpani Palpasi : tidak adanya nyeri tekan ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................



j.



Genetalia : Tidak terkaji ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................



k. Integumen : Inspeksi



: warna kulit terlihat sawo matang, distribusi rambut merata, tidak adanya bekas luka Palpasi : tidak adanya nyeri tekan ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................



l.



Ekstremitas  Atas Inspeksi







:



: terlihat bentuk tangan simetris kanan dan kiri, tidak adanya edema, tidak adanya bekas luka Palpasi : akral teraba hangat, CRT kurang dari 3detik ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... .................................................................................................................................. Bawah Inspeksi : bentuk kaki simetris antara kanan dan kiri, tidak adanya kelainan bentuk kaki, tidak ada benjolan Palpasi : turgor kulit elastis, CRT kurang dari 3detik ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ..................................................................................................................................



m. Neurologis :  Status mental dan emosi : Tingkat kesadaran penuh cuma Ny.R merasa lemas dengan kondisi saat ini ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ..................................................................................................................................  Pengkajian saraf kranial : Tidak terkaji ................................................................................................................................... ................................................................................................................................... 



Pemeriksaan refleks : Tidak dikaji ................................................................................................................................... ...................................................................................................................................



b. Pemeriksaan Penunjang 1. Data laboratorium yang berhubungan ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................



2. Pemeriksaan radiologi Tidak terdapat pemeriksaan radiologi ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................



3. Hasil konsultasi Disarankan untuk tidak berfikir berlebihan atau beraktifitas yang berlebihan, dan tidak mengkonsumsi daging yang berlebihan ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ 4. Pemeriksaan penunjang diagnostic lain Tidak ada pemeriksaan penunjang lainnya ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................



5.



ANALISA DATA A. Tabel Analisa Data DATA



Interpretasi (Sesuai dengan patofisiologi)



MASALAH



B. Tabel Daftar Diagnosa Keperawatan /Masalah Kolaboratif Berdasarkan Prioritas NO



TANGGAL / JAM DITEMUKAN



DIAGNOSA KEPERAWATAN



TANGGAL TERATASI



Ttd



C. Rencana Tindakan Keperawatan Hari/



No



Tgl



Dx



Rencana Perawatan Tujuan dan Kriteria Hasil



Intervensi



Ttd Rasional



D. Hari/ Tgl/Jam



Implementasi Keperawatan No Dx



Tindakan Keperawatan



Evaluasi proses



Ttd



E. No



Evaluasi Keperawatan Hari/Tgl Jam



No Dx



Evaluasi



TTd