FORMAT PENGKAJIAN GORDON.docx

LAPORAN KASUS

ASUHAN KEPERAWATAN PADA KLIEN DENGAN ................................... DI .................. RUMKITAL Dr. RAMELAN SURABAYA Tanggal .............. s/d ..................

LEMBAR PENGESAHAN

ASUHAN KEPERAWATAN PADA KLIEN DENGAN ................................... DI .................. RUMKITAL Dr. RAMELAN SURABAYA Tanggal .............. s/d ..................

PENGKAJIAN KEPERAWATAN ASUHAN KEPERAWATAN PSIKOSOSIAL STIKES HANG TUAH SURABAYA  Nama mahasiswa : ........................................ Tgl/jam pengkajian : ........................................ Diagnosa medis : ........................................ ........................................

I. IDENTITAS 1.  Nama 2. Umur 3. Jenis kelamin 4. Status 5. Agama 6. Suku/bangsa 7. Bahasa 8. Pendidikan 9. Pekerjaan 10. Alamat dan no. telp

: : : : : : : : : :

Tgl/jam MRS  No. RM Ruangan/kelas  No.kamar

: : : :

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

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

8. Riwayat kesehatan keluarga : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 9. Susunan keluarga (genogram) :

10. Riwayat alergi : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... III. POLA NUTRISI DAN METABOLIK  1. Pola makan Di rumah

Di rumah sakit

2. Buang air kecil Di rumah Di rumah sakit Frekuensi : .................................. Frekuensi : .................................. Jumlah : .................................. Jumlah : .................................. Warna : .................................. Warna : .................................. Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria ( ) retensi ( ) inkontinen Kateter : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari

V. POLA AKTIVITAS DAN LATIHAN 1. Kemampuan perawatan diri

Aktivitas Mandi Berpakaian/berdandan Eliminasi/toileting Mobilitas di tempat tidur Berpindah Berjalan  Naik tangga Berbelanja Memasak

0

SMRS 1 2 3

4

0

1

MRS 2

3

4

VII. POLA KOGNITIF DAN PERSEPTUAL Berbicara : ( ) normal ( ) gagap ( ) bicara tak jelas Bahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya, .................................... Kemampuan membaca : ( ) bisa ( ) tidak Tingkat ansietas : ( ) ringan ( ) sedang ( ) berat ( ) panik Sebab, ................................................................................................... Kemampuan interaksi : ( ) sesuai ( ) tidak, .................................................................... Vertigo : ( ) tidak ( ) ya  Nyeri : ( ) tidak ( ) ya

Bila ya, P Q R S T

: : : : :

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

VIII. POLA PERSEPSI DIRI / KONSEP DIRI 1. Body image/gambaran diri ( ) cacat fisik ( ) perubahan ukuran fisik ( ) fungsi alat tubuh terganggu ( ) keluhan karena kondisi tubuh

( ( ( (

) pernah operasi ) proses patologi penyakit ) kegagalan fungsi tubuh ) gangguan struktur tubuh

( ) merasa tidak berdaya

( ) enggan membicarakan masa depan

Jelaskan : ........................................................................................................................................... ........................................................................................................................................... Masalah keperawatan : ...................................................................................................................... IX. POLA PERAN DAN HUBUNGAN Pekerjaan : .......................................................................................................... Kualitas bekerja : .......................................................................................................... Hubungan dengan orang lain : Sistem pendukung : ( ) pasangan ( ) tetangga/teman ( ) tidak ada ( ) lainnya, ...................................................................................... Masalah keluarga mengenai perawatan di RS : ................................................................................... X. POLA SEKSUALITAS / REPRODUKSI Menstruasi terakhir : ..................................................................................................................... Masalah menstruasi : ..................................................................................................................... Pap smear terakhir : ..................................................................................................................... Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidak Masalah seksual yang berhubungan dengan penyakit : ............................................................... XI. POLA KOPING / TOLERANSI STRESS 1. Masalah utama selama MRS (penyakit, biaya, perawatan diri) ......................................................................................................................................................... .........................................................................................................................................................

2. Sistem Pernafasan ( Breath ) ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 3. Sistem Kardiovaskuler ( Blood  ) ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 4. Sistem Persarafan ( Brain  ) ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 5. Sistem Perkemihan ( Bladder  ) ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 6. Sistem Pencernaan ( Bowel ) ......................................................................................................................................................... .........................................................................................................................................................

XIV. PEMERIKSAAN PENUNJANG 1. Laboratorium ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 2. Photo ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 3. Lain-lain .........................................................................................................................................................

ANALISA DATA

 Nama klien Umur  No.

: .............................................. : .............................................. Data (Symptom)

Ruangan/kamar : ..............................................  No. RM : ..............................................

Penyebab (Etiologi)

Masalah (Problem)

PRIORITAS MASALAH

 Nama klien Umur  No.

: .............................................. : ..............................................

Masalah Keperawatan

Ruangan/kamar : ..............................................  No. RM : .............................................. Tanggal

Ditemukan

Teratasi

Paraf (Nama perawat)

RENCANA KEPERAWATAN

 No.

Diagnosa Keperawatan

Tujuan Dan Kriteria Hasil

Intervensi

Rasional

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

 No.

Waktu Tgl/jam

Tindakan

TT

Waktu Tgl/jam

Catatan Perkembangan (SOAP)

TT