FORMAT LAPORAN ASUHAN
KEPERAWATAN
BERDASARKAN
FORMAT GORDON
ASUHAN
KEPERAWATAN PADA ........................................
DENGAN
DIAGNOSA MEDIS ...........................................................
DI
...............................................................................................
TANGGAL…………………………………………………………………………
I. PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama :
.........................................................................................
Umur :
.........................................................................................
Agama :
.........................................................................................
Jenis
Kelamin :
...........................................................................................
Status :
...........................................................................................
Pendidikan :............................................................................................
Pekerjaan :
............................................................................................
Suku
Bangsa :............................................................................................
Alamat :
..........................................................................................
Tanggal
Masuk :
...........................................................................................
Tanggal
Pengkajian :
...........................................................................................
No.
Register :
.............................................................................................
Diagnosa
Medis :
............................................................................................
b. Identitas Penanggung Jawab
Nama :
............................................................................................
Umur :
.............................................................................................
Hub. Dengan Pasien :
...........................................................................................
Pekerjaan :
.............................................................................................
Alamat :
..............................................................................................
2. Status Kesehatan
a. 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
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
b. Satus Kesehatan Masa Lalu
1) Penyakit
yang pernah dialami
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2) Pernah
dirawat
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3) Alergi
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4) Kebiasaan
(merokok/kopi/alkohol dll)
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
c. Riwayat Penyakit Keluarga
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
d. 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 Perawatan Diri
|
0
|
1
|
2
|
3
|
4
|
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 : ……………………………………….
Tingkat kesadaran : komposmetis /
apatis / somnolen / sopor/koma
GCS :
verbal:……….Psikomotor:……….Mata :……………..
b. Tanda-tanda
Vital : Nadi
= ……… ,
Suhu =…………. , TD =…………, RR =………
c. Keadaan fisik
a. Kepala dan
leher :
........................................................................................................................................................................................................................................................................................................................................................................................................................
b. Dada :
· Paru
..........................................................................................................................................................................................................................................................................
· Jantung
...............................................................................................................................................................................................................................................................................................................................................................................................................
c. Payudara dan ketiak :
........................................................................................................................................................................................................................................................................................................................................................................................................................
d. abdomen :
........................................................................................................................................................................................................................................................................................................................................................................................................................
e. Genetalia :
........................................................................................................................................................................................................................................................................................................................................................................................................................
f. Integumen :
................................................................................................................................................................................................................................................................................
........................................................................................................................................
g. Ekstremitas :
· Atas
.........................................................................................................................................................................................................................................................................................................................................................................................................
· Bawah
.........................................................................................................................................................................................................................................................................................................................................................................................................
h. Neurologis :
· Status mental da emosi :
......................................................................................................................................................................................................................................................................
· Pengkajian saraf kranial :
......................................................................................................................................................................................................................................................................
· Pemeriksaan refleks :
......................................................................................................................................................................................................................................................................
b. Pemeriksaan
Penunjang
1. Data
laboratorium yang berhubungan
................................................................................................................................................................................................................................................................................................
................................................................................................................................................
................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................................................................................
2. Pemeriksaan
radiologi
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Hasil
konsultasi
................................................................................................................................................................................................................................................................................................
................................................................................................................................................
4. Pemeriksaan
penunjang diagnostic lain
................................................................................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................
5. ANALISA DATA
A. Tabel
Analisa Data
DATA
|
Etiologi
|
MASALAH
|
|
|
|
B. Tabel
Daftar Diagnosa Keperawatan /Masalah Kolaboratif Berdasarkan
Prioritas
NO
|
TANGGAL / JAM DITEMUKAN
|
DIAGNOSA KEPERAWATAN
|
TANGGAL
TERATASI
|
Ttd
|
|
C. Rencana
Tindakan Keperawatan
Hari/
Tgl
|
No Dx
|
Rencana Perawatan
|
Ttd
|
||
Tujuan dan Kriteria
Hasil
|
Intervensi
|
Rasional
|
|||
|
|
|
|
|
D. Implementasi Keperawatan
Hari/ Tgl/Jam
|
No Dx
|
Tindakan Keperawatan
|
Evaluasi proses
|
Ttd
|
|
|
|
E. Evaluasi Keperawatan
No
|
Hari/Tgl
Jam
|
No Dx
|
Evaluasi
|
TTd
|
|
|
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