FORMAT LAPORAN ASUHAN KEPERAWATAN

BERDASARKAN FORMAT GORDON

ASUHAN KEPERAWATAN PADA Tn. P
DENGAN DIAGNOSA MEDIS FRAKTUR FEMUR
DI RUMAH SAKIT
TANGGAL
I. PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama

: Tn. P.

Umur

: 30 Tahun

Agama

Jenis Kelamin

: Laki-laki

Status

Pendidikan

Pekerjaan

Suku Bangsa

: Indonesia

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)
- Nyeri Akut
2) Alasan masuk rumah sakit dan perjalanan penyakit saat ini
- Mengalami kecelakaan lalu lintas, hari ke-2 post operasi orif femur sinistra
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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Genogram

Ny.H.H
59 thn
An Z.P
20thn

An I. A
31thn

Keterangan :
: Laki-laki

: Garis Perkawinan

: Perempuan

: Garis keturunan

: Meninggal

: Pisah

: Klien

: Tinggal serumah

Penjelasan Genogram :
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d. Diagnosa Medis dan therapy
- Fraktur Femur
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
:
Pola konsumsi nutrisi-metabolik dalam batasan normal
Saat sakit
:

Harus lebih mengkonsumsi makanan dan minuman yang mengandung zat besi,
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. Polaaktivitas dan latihan

1) Aktivitas
Kemampuan

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
Dapat melakukan latihan dengan normal
Saat sakit
Sulit dalam melakukan latihan karena adanya nyeri
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
:
Pola tidur dan istrahat normal
Saat sakit
:
Sulit dalam tidur dan istrahat karena adanya nyeri
h. Pola Peran-Hubungan
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i. Pola Seksual-Reproduksi
Sebelum sakit
:
Pola seksual-reproduksi normal
Saat sakit
:
Terganggu karena adanya nyeri
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
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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
DO
Nyeri dengan skala 7

Etiologi
Cedera dan benturan saat
kecelakaan lalu lintas

MASALAH
Nyeri akut
Hambatan mobilitas
fsik

DS
Nyeri seperti tertusuk
Terasa sangat sakit
ketika merubah posisi

B. Tabel Daftar Diagnosa Keperawatan /Masalah Kolaboratif Berdasarkan Prioritas

NO

TANGGAL /
JAM
DITEMUKAN

DIAGNOSA KEPERAWATAN

TANGGAL
TERATASI

Ttd

II

C. Rencana Tindakan Keperawatan

Hari/
Tgl

Rencana Perawatan
Dx Keperawatan

Tujuan dan
Kriteria Hasil

Intervensi

Rasional

Nyeri akut berhubungan

NOC :

dengan:

Pain Level: 0

Agen injuri (biologi,

comfort level:

komprehensif termasuk lokasi,

kimia,

Merasa nyaman

karakteristik, durasi, frekuensi,

NIC :

fisik, psikologis),
kerusakan
jaringan
Nyeri akut (00132)
Domain 12 : Kenyamanan
Kelas 1 : Kenyamanan
Fisik

Lakukan pengkajian nyeri yang

kualitas dan faktor presipitasinya

Setelah dilakukan
tindakan

Ajarkan tentang teknik non

farmakologi: napas dalam,

keperawatan

relaksasi, distraksi, kompres

selama 3x24 jam,

hangat/ dingin

pasien tidak

Tingkatkan istirahat

Berikan informasi tentang nyeri

Definisi : Pengalaman

mengalami nyeri,

sensori dan emosi yang

dengan kriteria

tidak menyenangkan

hasil:

seperti penyebab nyeri, berapa lama

akibat adanya kerusakan

Mampu

nyeri akan berkurang dan antisipasi

jaringan yang aktual atau

mengontrol nyeri

ketidaknyamanan dari prosedur

potensial, atau di

(tahu penyebab

gambarkan dengan istilah

nyeri,

seperti (International

mampu

Associationfor the Study

menggunakan

of Pain), awitan yang tiba-

tehnik

tiba akut perlahan dengan

nonfarmakologi

intensitas ringan sampai

untuk mengurangi

berat dengan akhir yang

nyeri,

dapat diantisipasi atau

mencari bantuan)

dapat diramalkan dan

Melaporkan

durasinya kurang dari 6

bahwa nyeri

bulan.

berkurang dengan

DS:

menggunakan

- Nyeri seperti tertusuk

manajemen nyeri

- Terasa sangat sakit ketika

Menyatakan rasa

merubah posisi

nyaman

DO:

setelah nyeri

- Skala nyeri 7

berkurang

pemberian analgetik

Mampu memperagakan
teknik non
farmakologi untuk
mengurangi rasa
nyeri

Kolaborasikan dengan dokter dalam

Monitor vital sign sebelum dan

sesudah pemberian analgesik
pertama kali

Gangguan mobilitas fisik

NOC :

NIC :

Berhubungan dengan nyeri Mobility Level : Dapat

bergerak dengan
Domain 4 : akitivitas /

bebas.

istirahat
Kelas 2 : aktivitas / latihan
Defini
:
keterbatasan

Setelah dilakukan

dalam,

tindakan

pergerakan

Exercise therapy : ambulation

sebelum/sesudah latihan dan lihat

respon pasien saat latihan

fisik

mandiri dan terarah pada

Keperawatan selama

tubuh atau satu ekstremitas

3x24 gangguan

atau lebih.

mobilitas fisik teratasi

aktivitas fisik

- Nyeri seperti
tertusuk

Klien meningkat dalam

dengan kebutuhan

peningkatan

ketika merubah

mobilitas

posisi

Memverbalisasikan

DO:

perasaan dalam

- Skala nyeri 7

meningkatkan

terhadap cedera

Ajarkan pasien atau tenaga

kesehatan lain tentang teknik
ambulasi

Kaji kemampuan pasien dalam

mobilisasi

Latih pasien dalam pemenuhan

kekuatan dan

kebutuhan ADLs secara mandiri

kemampuan

sesuai kemampuan

berpindah

Bantu klien untuk menggunakan

tongkat saat berjalan dan cegah

Mengerti tujuan dari

- Terasa sangat sakit

Konsultasikan dengan terapi fisik

tentang rencana ambulasi sesuai

dengan kriteria hasil:

DS:

Monitoring vital sign

Memperagakan

mobilisasi dan bantu penuhi

penggunaan alat
Bantu untuk
mobilisasi (walker)

Dampingi dan Bantu pasien saat

kebutuhan ADLs .

Berikan alat Bantu jika klien

memerlukan.

Ajarkan pasien bagaimana merubah

posisi dan berikan bantuan jika
diperlukan

D.
Hari/
Tgl/Jam

Implementasi dan Evaluasi Keperawatan

No Dx

Implementasi Keperawatan

Evaluasi
S : Subjektif

Merasakan nyeri ketika lari

O : Objektif

Pain level : 3

A : Analisis
Masalah belum teratasi
P : Planning
Intervensi dilanjutkan (nomor
1,2,3 dan 4) yaitu, :

Lakukan pengkajian nyeri yang

komprehensif termasuk lokasi,
karakteristik, durasi, frekuensi,
kualitas dan faktor
presipitasinya

Ajarkan tentang teknik non

farmakologi: napas dalam,
relaksasi, distraksi, kompres
hangat/ dingin

Tingkatkan istirahat

Berikan informasi tentang nyeri

seperti penyebab nyeri, berapa
lama nyeri akan berkurang dan

Ttd

antisipasi ketidaknyamanan dari

prosedur