A.

DATA PENGKAJIAN KOMPREHENSIF (POLA FUNGSIONAL GORDON NARATIF)

1. Biodata Pasien

Nama : .........................................
Tempat/Tanggal Lahir : .........................................
Umur : .........................................
Agama : .........................................
Jenis Kelamin : .........................................
Pendidikan : .........................................
Suku : .........................................
Pekerjaan : .........................................
Tanggal Masuk RS : .........................................
Sumber Informasi : .........................................
Status Perkawinan : .........................................
Lama Bekerja : .........................................
Alamat : .........................................

Keluarga terdekat yang dapat dihubungi (orang tua, wali, suami, istri dan lain-lain):
Pekerjaan : .........................................
Pendidikan : .........................................
Alamat : .........................................

2. RIWAYAT KESEHATAN :
a. KELUHAN UTAMA :

b. RIWAYAT KESEHATAN SEKARANG

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c. RIWAYAT KESEHATAN DAHULU

d. RIWAYAT KESEHATAN KELUARGA

Genogram :

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A. Pengkajian Pola Kesehatan Fungsional
1. Pola persepsi kesehatan dan manajemen kesehatan
DS :
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DO :
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2. Pola nutrisi dan metabolik

DS
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DO
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3. Pola eliminasi
DS :
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DO :
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4. Pola aktivitas dan olahraga
DS
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DO
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5. Pola istirahat dan tidur

DS
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DO
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6. Pola kognitif dan persepsi
DS
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DO
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7. Pola persepsi diri dan konsep diri
DS
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DO
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8. Pola peran dan berhubungan (relationship)

DS
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DO
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9. Pola seksualitas dan reproduksi
DS
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DO
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 10. Pola koping dan Toleransi Stres
DS
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DO
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11. Pola nilai-nilai dan keyakinan : Pengkajian Aspek Spiritual (Format Hope)
a. H : HASIL /SUMBER KEKUATAN :
Sumber harapan, makna, kenyamanan, kekuatan, kedamaian, cinta
dan hubungan Kami telah mendiskusikan sistem pendukung Anda.
Saya bertanya-tanya, apa yang ada dalam hidup Anda yang memberi
Anda dukungan internal ?
Apa sumber harapan, kekuatan, kenyamanan dan kedamaian Anda?
Apa yang Anda tunggu selama masa-masa sulit?
Apa yang menopang Anda dan membuat Anda terus berjalan?
Bagi beberapa orang, kepercayaan agama atau spiritual mereka
bertindak sebagai sumber penghiburan dan kekuatan dalam
menghadapi pasang surut hidup ; Apakah ini benar untukmu Jika
jawabannya "ya," lanjutkan ke pertanyaan O dan P. Jika jawabannya
"tidak," pertimbangkan untuk bertanya: apakah pernah? Jika
jawabannya "Ya," tanyakan: Apa yang berubah?
b. O : ORGANIZED Keagamaan
Agama terorganisir Apakah Anda menganggap diri Anda bagian
dari agama yang terorganisir? seberapa penting ini untukmu? Aspek
apa dari agamamu sangat membantu dan tidak begitu membantu
kamu? Apakah Anda bagian dari komunitas religius atau spiritual?
Apakah itu membantu Anda? Bagaimana?
c. P: Personal Spiritualitas / keyakinan pribadi
Apakah Anda memiliki keyakinan spiritual pribadi yang tidak
bergantung pada agama yang terorganisir? Apakah mereka? Apakah
anda percaya kepada Tuhan? Hubungan macam apa yang Anda miliki
dengan Tuhan? Apa aspek spiritualitas atau praktik spiritual Anda
yang paling Anda sukai? (Misalnya, doa, meditasi, membaca kitab
suci, menghadiri ibadah keagamaan, mendengarkan musik, mendaki
gunung, berkomunikasi dengan alam)
E: Effect
Efek pada perawatan kesehatan dan masalah akhir masa Pernah
sakit (atau keadaan Anda saat ini) mempengaruhi kemampuan Anda

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 untuk melakukan hal-hal yang biasanya membantu Anda secara
spiritual? (Atau mempengaruhi hubungan Anda dengan Tuhan?)
Sebagai dokter, adakah yang dapat saya lakukan untuk membantu
akses Anda ke sumber daya yang biasanya membantu Anda? Apakah
Anda khawatir tentang konflik antara keyakinan dan situasi /
perawatan / keputusan medis Anda?
Apakah akan sangat membantu jika Anda berbicara dengan
pemimpin spiritual pendeta / pemimpin spiritual masyarakat?
Adakah praktik atau batasan spesifik yang harus saya ketahui dalam
memberikan perawatan medis Anda? (Misalnya, pembatasan diet,
penggunaan produk darah) Jika pasien sedang sekarat: Bagaimana
kepercayaan Anda mempengaruhi jenis perawatan medis yang Anda
inginkan untuk diberikan dalam beberapa hari / minggu / bulan ke
depan?

DS :..........................................................................................................................

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DO : ..........................................................................................................................

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3. ANALISA DATA

DATA – DATA HASIL PENGKAJIAN PROBLEM ETIOLOGI

(SYMTOM)
1.

2.

3.

5.

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 4. PEMERIKSAAN PENUNJANG MEDIK ( LAB/RONTGENT/SPUTUM DLL)

Tanggal
No Jenis Pemeriksaan Hasil Interpretasi
Pemeriksaan

5. Terapi yang diberikan

Waktu Jenis Terapi yang

No Dosis Terapi Cara Pemberian
Pemberian diberikan

6. DIAGNOSA KEPERAWATAN
a. Sususnlah Prioritas Masalah Keperawatan Sesuai

1. ……………………………………………………………………………………………………………………………

2. ……………………………………………………………………………………………………………………………

3. ……………………………………………………………………………………………………………………………

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4. ……………………………………………………………………………………………………………………………

5. ……………………………………………………………………………………………………………………………

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7. PERENCANAAN KEPERAWATAN

Data Kriteria Hasil Perencanaan

(NOC : SMAT) (NIC : ONEC)

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8. IMPLEMENTASI dari masalah utama

Hari / Tindakan Keperawatan Respon Pasien Paraf

Tanggal / (ONEC) Perawat
Waktu

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 9. EVALUASI / CACATAN PERKEMBANGAN dari masalah utama

Hari / Tanggal / Proses Evaluasi (SOAP) Paraf

Waktu Perawat
S:

O:

A : Masalah ………………………………………..
Masih Berlangsung / Teratasi sebagian / Teratasi *

P:

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 VI. EVALUASI ( NANDA )

Nama : Ruang : Dx:...................................

Umur : Dx Medis :

TTD
TGL EVALUASI (NANDA)
Perawat

Indikator Pencapaian
Awal Target
NOC H1: ............. H2: ............. H3: .............

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