ASUHAN KEPERAWATAN LANSIA

DENGAN HIPERTENSI

Disusun Untuk Memenuhi Tugas Program Pendidikan Profesi

Pada Stase Keperawatan Gerontik

Disusun oleh :
TIA NURCAHYANI,S.Kep
NIM I41B110016

PROGRAM PROFESI ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS LAMBUNG MANGKURAT
BANJARBARU
2015

ASUHAN KEPERAWATAN GERONTIK

PADA ............................................................................
Nama Mahasiswa

: Tia Nurcahyani, S.Kep

Tempat Praktek

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

Tanggal Praktek

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Tanggal pengkajian

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I. Identitas diri Klien

Nama
Umur
Jenis Kelamin
Alamat
Status Perkawinan
Agama
Suku
Pendidikan
Pekerjaan
Lama Bekerja
Sumber informasi
Tanggal masuk panti
Alasan di bawa ke panti

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II. Struktur Keluarga

No

Nama

.
1.
2.
3.
4.
5.
6.
7.
8.
Genogram

Umur

JK

Hub dengan klien

Pekerjaan

Ket

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III. Riwayat Penyakit Keluarga
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IV. Riwayat Penyakit

1.

2.

3.

4.

Keluhan utama saat ini :

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Apa yang dipikirkan saat ini : ............................................................................
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Siapa yang paling dipikirkan saat ini: ................................................................
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Riwayat penyakit dahulu : ..
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V. Pengkajian
1. Persepsi dan pemeliharaan kesehatan : ................................................................
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2. Pola Nutrisi : ........................................................................................................

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3. Pola eliminasi : .....................................................................................................
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4. Pola aktivitas dan latihan:
Kemampuan merawat diri
0
1
2
3
4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah/berjalan
Ambulasi/ROM
Keterangan: 0 : mandiri, 1: alat Bantu, 2: dibantu orang lain, 3 : dibantu orang lain
dan alat, 4 : tergantung total
5. Pola tidur dan istirahat :
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6. Pola perceptual
Penglihatan : .....................................................................................................
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Pendengaran : .....................................................................................................
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Pengecap
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7. Pola Persepsi diri : ................................................................................................
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8. Pola peran hubungan : ..
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9. Pola managemen koping stress : ...
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10.
Sistem
nilai
dan
keyakinan
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VI. Pemeriksaan Fisik
1. Pemeriksaan Fisik
a.
b.
c.
d.

e.

f.

g.

h.

Tingkat kesadaran : ..............................................................................................

TD : ................ mmHg
Nadi : .............. x/menit RR : ............... x/menit
Temperatur : ................... C
BB : .................. Kg TB : ............... cm
Kepala : ...............................................................................................................
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Thorax (bentuk dada, retraksi otot dada, turgor kulit ) : ......................................
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Abdomen (Ascites, kembung, nyeri tekan) : ........................................................
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Ekstrimitas (kekuatan otot) : ................................................................................
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2. Pemeriksaan panca indera
a. Penglihatan (mata)
1) Bola mata : .................................................................................................
2) Konjungtiva : .................................................................................................
3) Sklera
: .................................................................................................
4) Reflek pupil : .................................................................................................
5) Visus
: .................................................................................................
b. Pendengaran (telinga)
1) Bentuk telinga: ..............................................................................................
2) Nyeri tekan : ada / tidak ada
3) Liang telinga : serumen ada / tidak ada
4) Gangguan pendengaran : ada / tidak ada
5) Menggunakan alat bantu dengar ( )
c. Pengecapan
1) Gigi geligi : bersih / tidak, gigi tinggal bagian atas depan (
2) Lidah : bersih / tidak
3) Sensasi rasa manis ( ), asin (
), dan pahit ( )
d. Sensasi (kulit)
1) Sensasi nyeri ( ), Sensasi taktil (
2) Turgor kulit : baik / buruk
e. Penciuman (Hidung)
1)
2)
3)
4)

Lubang hidung
Septum nasi
Konka
Secret

: simetris / tidak
: lurus / tidak
: normal / tidak
: ada / tidak

), Sensasi suhu (

VII. Analisa Data

Data

Problem
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Etiologi
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Data
Problem
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Etiologi
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VIII. Diagnosa Sesuai Prioritas

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IX. Rencana Keperawatan

Diagnosa
Keperawatan

Rencana keperawatan
Tujuan

Intervensi

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Diagnosa
Keperawatan

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Rencana keperawatan

Tujuan

Intervensi

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X. Catatan Perkembangan
No.
Dx

Hari/Tanggal/Jam

Implementasi

Evaluasi

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No.
Dx

Hari/Tanggal/Jam

Implementasi

Evaluasi

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