FORMAT LAPORAN ASUHAN KEPERAWATAN

BERDASARKAN FORMAT GORDON

ASUHAN KEPERAWATAN PADA Nn. A
DENGAN DIAGNOSA MEDIS ...........................................
DI RUANGAN IGD RUMAH SAKIT SENTOSA
TANGGAL 21 MARET 2016
I. PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama

: Nn. A

Umur

: 14 Tahun

Agama

: Islam

Jenis Kelamin

: Perempuan

Status

: - ( Tidak terkaji)

Pendidikan

: SMA

Pekerjaan

: Pelajar

Suku Bangsa

: - ( Tidak terkaji)

Alamat

: - ( Tidak terkaji)

Tanggal Masuk

: 21 Maret 2016

Tanggal Pengkajian

: 21 Maret 2016

No. Register

:-

Diagnosa Medis

:-

b. Identitas Penanggung Jawab

Nama
: Nn. B
Umur

: - ( Tidak terkaji)

Hub. Dengan Pasien

: Ibu Kandung Pasien

Pekerjaan

: - (Tidak terkaji)

Alamat

: - (Tidak terkaji)

2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
Ketidakefektifan jalan nafas.
2) Alasan masuk rumah sakit dan perjalanan penyakit saat ini
Nafas pendek,sesak, irama irregular dan terdapat retraksi dada ketika inspirasi.
3) Upaya yang dilakukan untuk mengatasinya
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b. 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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c.

Riwayat Penyakit Keluarga

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Genogram

Ny.H.H
59 thn
An Z.P
20thn

An I. A
31thn

Keterangan :
: Laki-laki

: Garis Perkawinan

: Perempuan

: Garis keturunan

: Meninggal

: Pisah

: Klien

: Tinggal serumah

Penjelasan Genogram :
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d. 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. Polaaktivitas dan latihan
1) Aktivitas
Kemampuan
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
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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= 30 x / menit
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
DATA
Ds :
Klien kesulitan
bernafas
Ibu klien mengatakan
pasien sangat gelisah
Do :
Klien terlihat sesak
irama irregular
terdapat retraksi dada
ketika inspirasi
RR = 30 x / menit

Etiologi

MASALAH
Ketidakefektifan
bersih jalan nafas
Ketidakefektifan pola
nafas

B. Tabel Daftar Diagnosa Keperawatan /Masalah Kolaboratif Berdasarkan Prioritas

NO

TANGGAL /
JAM
DITEMUKAN

DIAGNOSA KEPERAWATAN

TANGGAL
TERATASI

Ttd

C. Rencana Tindakan Keperawatan

Hari/
Dx Keperawatan
Tgl
Tujuan dan Kriteria

Rencana Perawatan
Intervensi

Rasional

Hasil
NOC :
Respiratory status :
1 maret
Ventilation
2016
Domain 11: Keamanan/
Respiratory status :
Perlindungan
Airway patency
Aspiration Control
Kelas 2: Cidera Fisik
Setelah dilakukan
tindakan keperawatan
Definisi : Ketidakmampuan
selama ...x 24 jam, klien
untuk membersih kansekresi
menunjukkan keefetifan
atau obstruksi dari saluran
jalan nafas, dibuktikan
pernafasanuntuk
dengan kriteria hasil :
mempertahankan kebersihan o Mendemonstrasikan
batuk efektif dan suara
jalan nafas.
nafas yang bersih, tidak
Batasan Karakteristik :
ada dyspneu (mampu
- Dispneu, Penurunan
mengeluarkan
suara nafas
sputum,mampu bernafas
- Kelainan suara nafas
dengan mudah, tidak
(rales, wheezing)
adapursed lips)
- Kesulitan berbicara
o Menunjukkan jalan
nafas yang paten (klien
- Batuk, tidak efekotif atau
tidak merasa tercekik,
tidak ada
irama nafas,frekuensi
- Gelisah
pernafasan dalam
- Perubahan frekuensi
rentang normal, tidak
dan irama nafas
ada suara nafas
Faktor-faktor yang
abnormal)
berhubungan:
o Mampu
o Lingkungan : merokok,
mengidentifikasikan dan
mencegah faktor yang
menghirup asap rokok,
dapat menghambat jalan
perokok pasif-POK,
nafas
infeksi
o Fisiologis : disfungsi
neuromuskular,hiperpla
sia dinding bronkus,
alergi jalannafas,
asma.
o Obstruksi jalan nafas :
spasme jalan
nafas,sekresi tertahan,
banyaknya mukus,
adanyajalan nafas buatan,
sekresi bronkus, adanya
eksudat di alveolus,
adanya benda asing
dijalan nafas.

Senin/2

Ketidakefektifan Bersihan
Jalan Nafas (00031)

NIC : Airway suction

o Pastikan kebutuhan oral /
tracheal suctioning
o Auskultasi suara nafas
sebelum dan sesudah
suctioning.
o Informasikan pada klien
dan keluarga tentang
suctioning
o Minta klien nafas dalam
sebelum suction dilakukan.
o Berikan O2 dengan
menggunakan canulanasal
untuk memfasilitasi
suksion nasotrakeal
o Gunakan alat yang steril
sitiap melakukan tindakan
o Anjurkan pasien untuk
istirahat dan napas dalam
setelah kateter dikeluarkan
dari nasotrakeal
o Monitor status oksigen
pasien
o Ajarkan keluarga bagaimana
cara melakukan suksion
o Hentikan suksion dan berikan
oksigen apabila
pasienmenunjukkan
bradikardi, peningkatan
saturasi O2, dll.
Airway Management
o Buka jalan nafas, guanakan
teknik chin lift atau
jawthrust bila perlu
o Posisikan pasien untuk
memaksimalkan ventilasi
o Identifikasi pasien perlunya
pemasangan alat
jalannafas buatan
o Ajarkan Batuk Efektif
o Lakukan fisioterapi dada
jika perlu
o Atur intake untuk cairan
mengoptimalkan
keseimbangan.
o Monitor respirasi dan
status O2
o Keluarkan sekret dengan
batuk atau suction
o Auskultasi suara nafas, catat
adanya suara tambahan
o Lakukan suction pada

Ketidakefektifan pola
nafas
Definisi : Inspirasi
dan/atau ekspirasi yang
tidak member ventilasi
yang adekuat
Batasan Karakteristik :
Subjektif
Dispnea
Napas pendek
Objektif
RR: 30x/menit

NOC :
Respiratory status :
Ventilation
Respiratory status :
Airway patency
Vital sign Status
Kriteria Hasil :
Mendemonstrasikan
batuk efektif dan
suara nafas yang
bersih, tidak ada
sianosis dan dyspneu
(mampu
mengeluarkan
sputum, mampu
bernafas dengan
mudah, tidak ada
pursed lips)
Menunjukkan jalan
nafas yang paten
(klien tidak merasa
tercekik, irama
nafas, frekuensi
pernafasan dalam
rentang normal, tidak
ada suara nafas
abnormal)
Tanda Tanda vital
dalam rentang
normal (tekanan
darah, nadi,
pernafasan)

mayo
Berikan bronkodilator bila
perlu

NIC :
Airway Management
Buka jalan nafas, guanakan
teknik chin lift atau jaw
thrust bila perlu
Posisikan pasien untuk
memaksimalkan ventilasi
Identifikasi pasien perlunya
pemasangan alat jalan
nafas buatan
Pasang mayo bila perlu
Lakukan fisioterapi dada jika
perlu
Keluarkan sekret dengan
batuk atau suction
Auskultasi suara nafas, catat
adanya suara tambahan
Lakukan suction pada mayo
Berikan bronkodilator bila
perlu
Berikan pelembab udara
Kassa basah NaCl Lembab
Atur intake untuk cairan
mengoptimalkan
keseimbangan.
Monitor respirasi dan status
O2
Terapi Oksigen
Bersihkan mulut, hidung dan
secret trakea
Pertahankan jalan nafas yang
paten
Atur peralatan oksigenasi

Monitor aliran oksigen

Pertahankan posisi pasien
Onservasi adanya tanda
tanda hipoventilasi
Monitor adanya kecemasan
pasien terhadap oksigenasi
Vital sign Monitoring
Monitor TD, nadi, suhu, dan
RR
Catat adanya fluktuasi
tekanan darah
Monitor VS saat pasien
berbaring, duduk, atau
berdiri
Auskultasi TD pada kedua
lengan dan bandingkan
Monitor TD, nadi, RR,
sebelum, selama, dan
setelah aktivitas
Monitor kualitas dari nadi
Monitor frekuensi dan irama
pernapasan
Monitor suara paru
Monitor pola pernapasan
abnormal
Monitor suhu, warna, dan
kelembaban kulit
Monitor sianosis perifer
Monitor adanya cushing
triad (tekanan nadi yang
melebar, bradikardi,
peningkatan sistolik)
Identifikasi penyebab dari
perubahan vital sign

Senin/2
1 maret
2016

Ketakutan
Definisi : Respons terhadap
persepsi ancaman yang
secara sadar dikenal sebagai
bahaya

NOC :
Tingkat ketakutan :
keparahan manifestasi
rasa takut, ketegangan,
atau kegelisahan yang
berasal dari sumber

NIC :
Pengurangan ansietas :
meminimalkan rasa cemas,
ngeri, firasat, atauu kesulitan
yang berhubungan dengan
perkiraan sumbe bahaya

Batasan Karakteristik :
Subjektif :
Cemas
Gelisah
khawatir
kognitif :
mengidentifikasi objek rasa
takut
perilaku :
fokus menyempit pada
sumber rasa takut
psikologis :
peningkatan frekuensi
pernapasan dan napas
dangkal
Faktor yang berhubungan :
Terpisah dari istem
pendukung dalam situasi
yang berrpotensi
menimbulkan stres (mis,
perawatan di rumah sakit,
prosedur rumah sakit )

yang dapat dikenali

Tingkat ketakutan:
anakk-anak :
keparahan manifestasi
rasa takut, ketegangan,
atau kegelisahan yang
berasal dari sumbr yang
dapat dikenali pada
anak-anak dari usia 1
tahn sampai 17 tahun
Pengendaian diri
terhadap ketakutan:
Tindakan individu untuk
mengurangi atau
menurunkan perasaan
tidak mampu akibat rasa
takut, ketegangan, atau
kegelisahan yang
berasal dari sumber
yang dapat dikenali
Tujuan/kriteria hasil:
pasien akan
memperlihatkan
pengendali diri terhadap
ketakutan, dibuktikan
oeh indikator sebagai
berikut (sebutkan 1-5
tida pernah, jarang,
kadang-kadang, sering,
atau selalu
menunjukkan):
- mencari informasi
untuk menurunkan
ketakutan
- menghindari sumber
ketakutan bila
mungkin
- menggunakan teknik
ralaksasi untuk
menurunkan
ketakutan
- mengendaikan
respons ketakutan

yang tiddak teridentifikasi

Teknik Penenangan:
menurunkan ansietas pada
pasien yang mengalami
distres akut
Peningkatan koping:
Membantu pasien
beradaptasi dengan persepsi
stresor, perubahan, ata
ancaman yang mengganggu
pemenuhan tuntutan hidup
dan peran.

D.
Hari/
Tgl/Jam

Implementasi dan Evaluasi Keperawatan

No Dx

Implementasi Keperawatan

Ttd

Evaluasi
S : paisen masih merasa takut
akan hasil ujiannya
O:
A :masalah belum teratasi
P

:meneruskan

yang

sudah

intervensi
ada

ketakutan rasa cemas

akan