Format Pengkajian Gordon
Format Pengkajian Gordon
I. PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama : Ny. H
Umur : 45 tahun
Agama : Katolik
Jenis Kelamin : Perempuan
Status : Menikah
Pendidikan : SD
Pekerjaan : Swasta
Suku Bangsa : Timur
Alamat : Kaubun
Tanggal Masuk : 26 april 2018
Tanggal Pengkajian : 27 april 2018
No. Register : 00xxxx
Diagnosa Medis : angina pektoris
2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
Klien mengatakan nyeri dada sebelah kiri hilang timbul dialami kurang lebih 2 minggu,nyeri
dada tembus kebelakang,mual,nyeri ulu hati,demam dan pusing
2) Pernah dirawat
Klien mengatakan perna dirawat sebelumnya
3) Alergi
Klien mengatakan tidak mempunyai alergi obat-obatan dan makanan
b. Pola Nutrisi-Metabolik
Sebelum sakit :
Klien mengatakan 3x sehari
Sarapan pagi
Makan siang
Makan malam
Saat sakit :
Klien mengatakan tidak pernah menghabiskan makanan yang dari rumah sakit
c. Pola Eliminasi
1) BAB
Sebelum sakit :
.klien mengatakan bab yang lancar pada saat sebelum sakit
Saat sakit :
Klien mengatakan bab yang tidak lancar pada saat sakit
2) BAK
Sebelum sakit :
Klien mengatakan bak yang lancar sebelum sakit
Saat sakit :
Klien mengatakan bak yang lancar pada 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
Klien mengatakan sehari-hari beraktivitas,bekerja sebagai swasta
Saat sakit
Klien mengatakan selama dirawat hanya istirahat untuk memulihkan kesehatan
Saat sakit :
Klien mengatakan istirahat yang kurang
h. Pola Peran-Hubungan
klien mengatakan terlihat hubungan pasien dengan keluarga sangat baik
i. Pola Seksual-Reproduksi
Sebelum sakit :
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Saat sakit :
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k. Pola Nilai-Kepercayaan
klien mengatakan saat sakit jarang melakukan dan saat sehat kadang-kadang beribadah
4. Pengkajian Fisik
a. Keadaan umum : sedang
Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma
GCS : verbal 5 Psikomotor: 6 Mata : 4
b. Tanda-tanda Vital : Nadi = ……… , Suhu =…………. , TD =…………, RR =………
c. Keadaan fisik
a. Kepala dan leher :
berbentuk bulat,simetris dan leher simetris
b. Dada :
Paru
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Jantung
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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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Dst
C. Rencana Tindakan Keperawatan
Hari Rencana Perawatan TTD
No
/
Dx Tujuan dan Kriteria Hasil Intervensi
Tgl
D. Implementasi Keperawatan
E. Evaluasi Keperawatan
Hari/Tgl TT
No. DX Evaluasi
Jam d
1 S:
O:
A:
P: