FORMAT PENGKAJIAN GORDON

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

LAPORAN ASUHAN KEPERAWATAN
BERDASARKAN FORMAT GORDON

I. PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama : Eric Crismasson Togatorop
Umur : 19 Tahun
Agama : Kristen Protestan
Jenis Kelamin : Laki-Laki
Status : Belum Menikah
Pendidikan : Mahasiswa
Pekerjaan : Pelajar
Suku Bangsa : Batak Toba
Alamat : Jl. Tarutung, Kec. Siborongborong, Kab. Taput
Tanggal Masuk : 10-10-2016
Tanggal Pengkajian : 12-10-2016
No. Register : 00082-277-991-858
Diagnosa Medis :

b. Identitas Penanggung Jawab

Nama : Elwin Togatorop
Umur : 20 tahun
Hub. Dengan Pasien : Saudara
Pekerjaan : Progamer
Alamat : Siborongborong
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 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 : ……………………………………….
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

1. a. Data Subjektif Perubahan Status Kesehatan Ansietas

Pasien mengatakan
masih memikirkan
keadaannya, merasa
cemas akan penyakitnya
dan tindakan operasi
yang akan dijalaninya.
Pasien mengatakan
tidak merasa nyaman
dengan kondisinya.

b. Data Objektif
 Hasil pengukuran
TTV ;
 Suhu : 37C,
 Nadi : 100 x/ mnt,
 RR : 24 x/ mnt, dan
 TD :130/90 mmHg.
 Pasien tampak
cemas,
 pasien tampak
gelisah
 sedikit berkeringat
 pasien tampak tidak
nyaman dengan
nyeri yang
dialaminya..
 rentang respon
ansietas sedang

2. a. Data Subjektif Ganguan neuromuskular Gangguan Menelan

Pasien mengatakan
tidak dapat makan
dan minum karena
saat makan dan
minum langsung
tersedak, nyeri dan
kering pada bagian
tenggorokan.

b. Data Objektif
 Pasien
 muntah
seperti dahak
 Batuk
 Pasien
tampak
lemas
 Observasi
TTV : TD
100/90
mmhg
 T 36,5C
 P 82x/i
 RR 22x/i
 B. Tabel Daftar Diagnosa Keperawatan /Masalah Kolaboratif Berdasarkan Prioritas

NO TANGGAL / DIAGNOSA KEPERAWATAN TANGGAL Ttd

JAM TERATASI
DITEMUKAN

1. 11-10-2016 Ansietas berhubungan dengan Perubahan

Status Kesehatan ditandai dengan Pasien
mengatakan masih memikirkan keadaannya,
merasa cemas akan penyakitnya dan tindakan
operasi yang akan dijalaninya, Pasien juga
mengatakan tidak merasa nyaman dengan
kondisinya. Pasien tampak cemas, pasien tampak
gelisah, sedikit berkeringat, pasien tampak tidak
nyaman dengan nyeri yang dialaminya dan
rentang respon ansietas sedang.
Observasi TTV :
 Suhu : 37C,
 Nadi : 100 x/ mnt,
 RR : 24 x/ mnt, dan
 TD :130/90 mmHg

2. 11-10-2016 Gangguan Menelan berhubungan dengan

Ganguan neuromuskular ditandai dengan Pasien
mengatakan tidak dapat makan dan minum
karena saat makan dan minum langsung tersedak,
nyeri dan kering pada bagian tenggorokan. Pasien
muntah seperti dahak , Batuk dan Pasien tampak
lemas.
Observasi TTV :
 TD 100/90 mmhg
 T 36,5C
 P 82x/i
 RR 22x/i
 C. Rencana Tindakan Keperawatan
Rencana Perawatan Ttd
Hari/ No
Tujuan dan Kriteria
Tgl Dx Intervensi Rasional
Hasil
11-10- 1 Setelah diberikan Anxiety Reduction
Anxiety Reduction  Klien dapat
2016 asuhan keperawatan
 Mendengarkan mengungkapkan
selama 3 x 24 jam penyebab kecemasan penyebab
klien dengan penuh kecemasannya sehingga
diharapkan klien tidak
perhatian perawat dapat
mengalami kecemasan, menentukan tingkat
 Observasi tanda kecemasan klien dan
dengan kriteria hasil : verbal dan non verbal menentukan intervensi
NOC: anxiety level dari kecemasan klien untuk klien selanjutnya.
 mengobservasi tanda
Calming Technique verbal dan non verbal
Tingkat Kecemasan dari kecemasan klien
 Menganjurkan keluarga
pada klien berkurang. dapat mengetahui
untuk tetap mendampingi
tingkat kecemasan yang
klien
klien alami.

Calming Technique
 Mengurangi atau
menghilangkan  Dukungan keluarga
rangsangan yang dapat memperkuat
menyebabkan kecemasan mekanisme koping
pada klien klien sehingga tingkat
ansietasnya berkurang

Coping enhancement  Pengurangan atau

penghilangan rangsang
 Meningkatkan penyebab kecemasan
pengetahuan klien dapat meningkatkan
mengenai glaucoma. ketenangan pada klien
dan mengurangi tingkat
 Menginstruksikan kecemasannya
klien untuk
menggunakan Coping enhancement
tekhnik relaksasi
 Peningkatan
pengetahuan tentang
penyakit yang dialami
klien dapat membangun
mekanisme koping

11-10- 2. Setelah dilakukan 1.Tinggikan kepala tempat tidur
2016 tindakan keperawatan pasien 90 selama makan dan 30
selama 3x24 jam, nutrisi menit selama makan
seimbang dengan kriteria
Pasien dapat 2.Atur pasien dalam posisi
menunjukkan metode miring saat berbaring
menelan makanan yang
tepat tanpa menimbulkan 3.Pantau asupan dan haluaran
keputusasaan. pasien dan timbang berat badan
setiap hari hingga stabil
4.Konsultasi dengan ahli gizi
untuk memodifikasi diet pasien
dan lakukan penghitungan kalori
sesui keperluan
5.Berikan perawatan mulut 3 x
sehari
6. Sajikan makanan dengan
tampilan yang menarik; anjurkan
pasien untuk mencium dan
melihat makanan. Bersihkan
peralatan yang kotor, kendalikan
bau, dan ciptakan suasana yang
tenang untuk makan
7. Lakukan pemasangan NGT (
jika keadaan belum baik )
klien terhadap
kecemasan yang
dialaminya
 Tekhnik relaksasi
yang diberikan pada
klien dapat mengurangi
ansietas
1. Untuk menurunkan
resiko aspirasi
2. Untuk menurunkan
resiko aspirasi
3. Dengan
mengevaluasi asupan
makanan perhari
memungkinkan semua
modifikasi yang
diperlukan dapat
dilakukan dengan cepat
4. Untuk menentukan
kebutuhan nutrisi
5.Untuk meningkatkan
nafsu makan pasien
6. Suasana yang tenang
dapat menstimulasi
nafsu makan; aroma
makanan menstimulasi
saliva
7. untuk mencukupi
kebutuhan nutris pasien
 D. Implementasi Keperawatan
Hari/ No Ttd
Tindakan Keperawatan Evaluasi proses
Tgl/Jam Dx
12-10-2016 1
07.00 1. Mengkaji tingkat ansietas 1.Rentang respon ansietas
pasien sedang.
10.00 2. Mengobservasi tanda - tanda vital 2.Observasi TTV :
S : T : 37ºC
N : 80/menit
RR : 23/menit
TD : 120/70 mmHg

11.00 3. Membatasi jumlah pengunjung 3.Pasien tampak lebih tenang

untuk beristirahat

11.15 4. Memberi kesempatan kepada pasien 4.Pasien tampak antusias

memberikan keluhannya
untuk mengungkapkan keluhannya

11.40 5. Pasien dapat melakukan

5. Mengajarkan pasien teknik distraksi
tehnik distraksi dan relaksasi
dan relaksasi dengan baik

13.00 6. Menganjurkan Keluarga untuk 6. Keluarga tampak mengerti

dan melakukan
selalu medampingi pasien

7. Pasien tampak memberikan

7. Meningkatkan pengetahuan klien
14.00 perhatiaanya terhadap informasi
mengenai ansietas yang di berikan
12-10-2016
07.00 2.

E. Evaluasi Keperawatan
Hari/Tgl
No No Dx Evaluasi TTd
Jam
Diposkan oleh Nyoman Adi Sedana di 00.19
Kirimkan Ini lewat EmailBlogThis!Berbagi ke TwitterBerbagi ke FacebookBagikan ke
Pinterest