Nama Mahasiswa : _________________________ Ruangan : ____________________

Nim : _________________________ Tgl. Praktek : ____________________

FORMAT LAPORAN ASUHAN KEPERAWATAN
(BERDASARKAN FORMAT GORDON)

I. PENGKAJIAN
1. Identitas Pasien
Nama                       : ____________________________________________________
Umur                      : ____________________________________________________
Agama                     : ____________________________________________________
Jenis Kelamin          : ____________________________________________________
Status                       : ____________________________________________________
Pendidikan               : ____________________________________________________
Pekerjaan                 : ____________________________________________________
Suku Bangsa            : ____________________________________________________
Alamat                    : ____________________________________________________
Tanggal Masuk       : ____________________________________________________
Tanggal Pengkajian : ____________________________________________________
No. Register            : ____________________________________________________
Diagnosa Medis      : ____________________________________________________

2. Identitas Penanggung Jawab

Nama                      : ____________________________________________________
Umur                       : ____________________________________________________
Hub. Dengan Pasien: ____________________________________________________
Pekerjaan                 : ____________________________________________________
Alamat                     : ____________________________________________________
II. RIWAYAT KESEHATAN
1. Riwayat Kesehatan Saat Ini (Keluahan Utama) :
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
2. Riwayat Kesehatan Dahulu :
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
3. Riwayat Penyakit Keluarga :
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Genogram :

Keterangan :
III. PEMERIKSAAN FISIK
Keadaan umum : Klien tampak sakit ringan / sedang / berat / tidak tampak sakit
Tingkat kesadaran : composmetis / apatis / somnolen / sopor / koma
GCS            : Verbal :________ Jumlah
Motorik :________
Eye :________
Tanda-tanda Vital : TD : ___________mmHg Suhu : ________ºC
N : ___________×/menit RR : ________×/menit
TB : ___________cm BB : ________kg
Keadaan fisik
 Kepala : ________________________________________________________
:________________________________________________________
 Mata : ________________________________________________________
:________________________________________________________
 Hidung : ________________________________________________________
:________________________________________________________
 Telinga : ________________________________________________________
:________________________________________________________
 Mulut : ________________________________________________________
:________________________________________________________
 Leher : ________________________________________________________
:________________________________________________________
 Dada : ________________________________________________________
:________________________________________________________
 Abdomen : ________________________________________________________
:________________________________________________________
 Integument : ________________________________________________________
:________________________________________________________
 Ekstrminas : ________________________________________________________
:________________________________________________________
 Genetalia : ________________________________________________________
:________________________________________________________
IV. POLA KEBUTUHAN DASAR ( DATA BIO-PSIKO-SOSIO-KULTURAL-
SPIRITUAL)
1. Pola Persepsi dan Manajemen Kesehatan
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2. Pola Nutrisi-Metabolik
 Sebelum sakit :
_________________________________________________________________
_________________________________________________________________
 Saat sakit           :
_________________________________________________________________
_________________________________________________________________
3. Pola Eliminasi
BAB
 Sebelum sakit  :
_________________________________________________________________
_________________________________________________________________
 Saat sakit           :
_________________________________________________________________
_________________________________________________________________
BAK
 Sebelum sakit    :
_________________________________________________________________
_________________________________________________________________
 Saat sakit             :
_________________________________________________________________
_________________________________________________________________
4. Pola aktivitas dan latihan
Aktivitas
nilai Keterangan
Aktivitas
0 1 2 3 4 0 : mandiri
Kemampuan Perawatan Diri 1 : alat bantu
Makan dan minum 2 : dibantu orang lain
Mandi 3: dibantu orang lain & alat
Toileting 4 : tergantung penuh
Berpakaian
Berpindah

Latihan
 Sebelum sakit :
_________________________________________________________________
_________________________________________________________________
 Saat sakit       :
_________________________________________________________________
_________________________________________________________________ 
5. Pola kognitif dan Persepsi
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6. Pola Persepsi-Konsep diri
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7. Pola Tidur dan Istirahat
 Sebelum sakit :
_________________________________________________________________
_________________________________________________________________
 Saat sakit             :
_________________________________________________________________
_________________________________________________________________

8. Pola Peran-Hubungan
 ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
9. Pola Seksual-Reproduksi
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
10. Pola Toleransi Stress-Koping
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
11. Pola Nilai-Kepercayaan
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
V. PEMERIKSAAN PENUNJANG
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
VI. TERAPI
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________