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format asuhan keperawatan tesis mahasiswa

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)
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
..................................................................................................................
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
............................................................................................................................................................
............................................................................................................................................................
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............................................................................................................................................................

............................................................................................................................................................
..................................................................................................................

3) Alergi
............................................................................................................................................................
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............................................................................................................................................................
............................................................................................................................................................
.........................................................................................................................
4) Kebiasaan (merokok/kopi/alkohol dll)
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
..................................................................................................................
c.

Riwayat Penyakit Keluarga
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................

............................................................................................................................................................
..................................................................................................................

d. Diagnosa Medis dan therapy
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
....................................................................................................................................

a.

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

………

, Suhu =…………. , TD =…………, RR =………

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

B. Tabel Daftar Diagnosa Keperawatan /Masalah Kolaboratif Berdasarkan Prioritas
NO

TANGGAL /
JAM
DITEMUKAN

DIAGNOSA KEPERAWATAN

TANGGAL
TERATASI

Ttd

C. Rencana Tindakan Keperawatan
Rencana Perawatan
Hari/ No
Tujuan dan Kriteria
Intervensi
Tgl
Dx
Hasil

Ttd
Rasional

D.
Implementasi Keperawatan
Hari/
No Dx
Tindakan Keperawatan
Tgl/Jam

Evaluasi proses

Ttd

E.

Evaluasi Keperawatan
Hari/Tgl
No
Jam

No Dx

Evaluasi

TTd

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