FORMAT LAPORAN ASUHAN KEPERAWATAN

BERDASARKAN FORMAT GORDON

ASUHAN KEPERAWATAN PADA ........................................

DENGAN DIAGNOSA MEDIS ...........................................................
DI ...............................................................................................
TANGGAL…………………………………………………………………………

I. PENGKAJIAN
1. Identitas
1. Identitas Pasien
Nama : Ny .p
Umur : 60 th
Agama : .........................................................................................
Jenis Kelamin : perempuan
Status : ...........................................................................................
Pendidikan :............................................................................................
Pekerjaan : ............................................................................................
Suku Bangsa :............................................................................................
Alamat : ..........................................................................................
Tanggal Masuk : ...........................................................................................
Tanggal Pengkajian : ...........................................................................................
No. Register : .............................................................................................
Diagnosa Medis : ............................................................................................

2. Identitas Penanggung Jawab

Nama : ............................................................................................
Umur : .............................................................................................
Hub. Dengan Pasien : ...........................................................................................
Pekerjaan : .............................................................................................
Alamat : ..............................................................................................
2. Status Kesehatan
1. Status Kesehatan Saat Ini
1. Keluhan Utama (Saat MRS dan saat ini)
- Saat MRS : pada saat masuk rumah sakit pasien mengeluh batuk lebih dari 4 minggu dan
nyeri pada dada saat batuk sputum warna kuning kehijauan
- Ssat pengkajian : pasie mengeluh nyeri pada dada saat batuk

2. Alasan masuk rumah sakit dan perjalanan penyakit saat ini

Pasien mengatakan batuk lebih dari 4 minggu dan sudah di periksakan ke klinik dekat
rumahnya tetapi batuk tersebut tak kunjung hilang dan nyeri pada dada saat batuk dan di
bawalah ke RS

3. Upaya yang dilakukan untuk mengatasinya

Pasien mengeluh batuk lebih dari 4 minggu dan sudah di periksakan ke klinik dekat
rumahnya tetapi batuk tersebut tak kunjung hilang dan nyeri pada dada saat batuk dan di
bawalah ke RS

2. 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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3. Riwayat Penyakit Keluarga
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4. 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
M a n d i
T o i l e t i n g
B e r p a k a i a n
B e r p i n d a h
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
D A T A E T I O L O G I M A S A L A H
 (Sesuai dengan patofisiologi)

B. Tabel Daftar Diagnosa Keperawatan /Masalah Kolaboratif Berdasarkan Prioritas

NO TANGGAL / JAM DITEMUKAN D I A G N O S A K E P E R A W A T A N T A N G G A L T t d
TERATASI

1. bersihan jalan nafas tidak efektif

berhubungan dengan sekresi yang tertahan di tandai dengan
batuk tidak efektf dan sputum berlebihan

2. Pola nafas tidak efektif berhubungan dengan hambatan

Upaya nafas di tandai dengan px mengeluh nyeri pada dada
Saat nafas

3. Nyeri akut berhubungan dengan agen pencedera

fisioligis ditandai dengan px mengeluh nyeri pada bagian
dada

C. Rencana Tindakan Keperawatan

Hari/ No Dx R e n c a n a P e r a w a t a n Ttd
Tgl
Tujuan dan Kriteria Hasil I n t e r v e n s i R a s i o n a l

Setelah di berikan tindakan M a n a j e m e n j a l a n n a f a s : 1.penurunan bunyi nafas

Tindakan keperawatan kebersihan Indikasi atelektasi ,ronki
1.
Jalan nafas efektif dengan kriteria Indikasi akumulasi secret/
identifik
Hasil Ketidakmampuan
asi px
Membersihkan jalan nafas
1.mempertahankan jalan nafas px untuk
Sehingga otot aksesori
memasu
2.mengeluarkan sekret tanpa Digunakan dan kerja
kkan
Pernafasan meningkat
Bantuan alat
2.pengeluaran sulit bila
pembuk
3.menunjukkan prilaku untuk Secret tebal,sputum
a jalan
Berdarah akibat
Memperbaiki bersihan jalan nafas nafas
Kerusakan paru atau luka
2.Buang
4.berpartisipas dalam program Bronchial yang
sekret
memerlukan
Pengobatan sesuai kondisi dengan
Evaluasi/intervensi
Memoti
5.mengidentifikasi potensial lanjutan
vasi px
3.membantu
Komplikasi dan melakukan untuk
mengencerkan
tindakan melakuk
Secret sehingga mudah
an
tepat Dikeluarkan
Batuk
4.mencegah pengeringan
atau
Membran mukosa
menyed
ot lendir
3.instruk
Setelah di berikan tindakan
sikan
Tindakan keperawatan nyeri yang 1.Untuk mengetahui tingkat
bagaima
Dirasakan klien dengan kriteria nyeri pasien
na agar 2. Untuk mengetahui tingkat
Hasil Bisa ketidaknyamanan dirasakan
melakuk oleh pasien
1.klien melaporkan nyeri berkurang
an batuk 3. Untuk mengalihkan
2.klien dapat mengenal lamanya efektif perhatian pasien dari rasa

4.ajarka nyeri
Nyeri
n px 4.   Untuk mengetahui apakah
nyeri yang dirasakan klien
bagaima
3. klien dapat menggambarkan na berpengaruh terhadap

Menggu yang lainnya

Faktor penyebab nyeri
nakan in
5. Untuk mengurangi tingkat
healer
ketidaknyamanan yang
sebagai
4.klien dapat menggunakan teknik dirasakan klien.
Maname
6. Pemberian analgetik
Non farmakologi stinya
dapat mengurangi rasa
nyeri pasien
5.klien menggunakan analgesik

Sesuai instruksi

Manajemen nyeri :

1. lakuka pengkajian nyeri

Komprehensif yang meliputi

Lokasi ,karakteristik,onset/durasi,

Frekuensi,kualitas,intensitas atau

Beratnya nyeri dan faktor

Pencetus

2. observasi adanya petunjuk

Non verbal mengenai

kenyamanan 5

Terutama pada mereka yang

tidak

Dapat berkomunikasi secara

Efektif

3. berikan informasi mengenai

 Nyeri. Seperti penyebab nyeri,

Berapa lama nyeri akan

dirasakan,

Dan antsipasi dari

Ketidaknyamanan akibat
prosedur

4. berikan individu penurun nyeri

Yang optimal dengan peresepan

analgesik

D. Implementasi Keperawatan
T t d
Hari/ Tgl/Jam N o D x Tindakan Keper awat a n E v a l u a s i p r o s e s
E. Evaluasi Keperawatan
H a r i / T g l
N o N o D x E v a l u a s i T T d
Jam