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)

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2)      Alasan masuk rumah sakit dan perjalanan penyakit saat ini

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3)      Upaya yang dilakukan untuk mengatasinya

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b.      Satus Kesehatan Masa Lalu

1)      Penyakit yang pernah dialami

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2)      Pernah dirawat

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3)      Alergi

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4)      Kebiasaan (merokok/kopi/alkohol dll)

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c.       Riwayat Penyakit Keluarga

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d.      Diagnosa Medis dan therapy

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3.      Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)

a.       Pola Persepsi dan Manajemen Kesehatan

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b.      Pola Nutrisi-Metabolik

·   Sebelum sakit          :

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·   Saat sakit                 :

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c.       Pola Eliminasi

1)   BAB

·   Sebelum sakit          :

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·   Saat sakit                 :

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2)   BAK

·      Sebelum sakit       :

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·      Saat sakit              :

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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

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·    Saat sakit          

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e.       Pola kognitif dan Persepsi

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f.       Pola Persepsi-Konsep diri

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g.       Pola Tidur dan Istirahat

· Sebelum sakit          :

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· Saat sakit                 :

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h.      Pola Peran-Hubungan

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i.        Pola Seksual-Reproduksi

·   Sebelum sakit     :

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·   Saat sakit                        :

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j.        Pola Toleransi Stress-Koping

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k.      Pola Nilai-Kepercayaan

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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       :

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b.      Dada  :

·   Paru

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·   Jantung

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c.       Payudara dan ketiak   :

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d.      abdomen        :

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e.       Genetalia        :

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f.       Integumen :

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g.       Ekstremitas     :

·         Atas

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·         Bawah

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h.      Neurologis      :

·         Status mental da emosi :

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·         Pengkajian saraf kranial :

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·         Pemeriksaan refleks :

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b.      Pemeriksaan Penunjang

1.      Data laboratorium yang berhubungan

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2.      Pemeriksaan radiologi

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3.      Hasil konsultasi

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4.      Pemeriksaan penunjang diagnostic lain

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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