my profile

Jumat, 16 Maret 2012

FORMAT PENGKAJIAN GORDON


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


































1 komentar: