ASUHAN KEPERAWATAN LANSIA PADA Tn.

NK DENGAN
HIPERTENSI DI BANJAR PUSEH, DESA KETEWEL,
KEC. SUKAWATI, KAB.GIANYAR
TANGGAL 24-26 MARET 2015

I. PENGKAJIAN
Pengkajian dilaksanakan pada tanggal 24 Maret 2015 pukul 17.00 wita di
rumah Tn.NK di Banjar Puseh, Desa Ketewel, Kec. Sukawati, Kab. Gianyar.
Data diperoleh dari hasil wawancara, observasi, dan pemeriksaan fisik.
A. DATA BIOGRAFI
Nama Pasien
Jenis Kelamin
Golongan darah
Tempat & tanggal lahir
Pendidikan terakhir
Agama
Status perkawinan
Tinggi badan/berat badan
Penampilan
Alamat

: Tn. NK
: Laki-Laki
::: SD
: Hindu
: Cerai Mati
: 160 cm / 48 kg
: Rapi dan cukup bersih
: Br. Puseh, Desa Ketewel, Kec. Sukawati,

Diagnose medis
Penanggung jawab
Nama
Hub. dengan pasien
Alamat

Kab. Gianyar
: Hipertensi
:
: Ny. WH
: Cucu
: Br. Puseh Desa Ketewel, Kec. Sukawati,

Kab. Gianyar
Telepon

: 085237652090

B. Riwayat Keluarga
Genogram
:

Keterangan :
= meninggal
= laki-laki masih hidup
= perempuan masih hidup

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

= hubungan perkawinan
= pasien
= tinggal serumah

C. Riwayat Pekerjaan
1. Pekerjaan saat ini : saat pengkajian pasien mengatakan sudah tidak
bekerja lagi, ia hanya bisa tinggal di rumah bersama dengan anak dan
cucunya.
2. Alamat pekerjaan : tidak ada alamat pekerjaan karena pasien hanya
bisa tinggal di rumah.
3. Berapa jarak dari rumah : jarak tidak dapat ditentukan karena pasien
tidak bekerja.
4. Alat transportasi : tidak ada alat transportasi yang digunakan karena
pasien tidak bekerja.
5. Pekerjaan sebelumnya

: pasien mengatakan dulunya ia bekerja

sebagai petani di sawah miliknya.

6. Berapa jarak dari rumah : 3 km
7. Alat transportasi : pasien mengatakan pergi ke tempat kerja selalu
dengan berjalan kaki.
8. Sumber pendapatan dan kecukupan terhadap kebutuhan : pasien
mengatakan semua kecukupan terhadap kebutuhan dipenuhi oleh anakanaknya.
D. Riwayat Lingkungan Hidup
Type tempat tinggal
: permanen
Kamar
: luas 3 m x 3 m
Kondisi tempat tinggal
: cukup bersih, sedikit berantakan, dan tidak
terdapat pencahayaan sinar matahari dari

balik jendela karena jendela tertutup dan

berbau.
Jumlah orang yang tinggal dalam satu rumah : tujuh orang
Derajat privasi
: pasien memiliki ruangan sendiri untuk
beristirahat
E. Riwayat Rekreasi
Hobbi/minat

: pasien mengatakan saat ini pasien senang berada di

rumah bersama cucu dan kegiatan yang biasa

dilakukan adalah menyapu di halaman rumah.

Keanggotaan dalam organisasi : pasien mengatakan tidak mengikuti
Liburan/perjalanan

keanggotaan dalam organisasi apapun.

: pasien mengatakan tidak pernah mengikuti liburan
atau perjalanan kemanapun.

F. Sistem Pendukung
Perawat/bidan/dokter/fisioterapi

: pasien mengatakan sering pergi ke

dokter yang diantar oleh cucu dan anaknya untuk

memeriksakan dirinya apabila obatnya sudah habis.
Jarak dari rumah
: 500 m
Rumah sakit
: Ganesha jaraknya 5 km
Klinik
: - Jaraknya - km
Pelayanan kesehatan di rumah
: pasien mengatakan tidak pernah
mendapatkan pelayanan kesehatan di
rumah
Makanan yang dihantarkan : pasien mampu makan sendiri dan makanan
disiapkan oleh keluarga, pasien saat ini menjaga
pola makan dengan pantangan makanan tertentu.
Perawatan sehari-hari yang dilakukan keluarga : pasien mengatakan selalu
diberikan perhatian dan dirawat oleh anak dan
cucunya.
Kondisi lingkungan rumah : kondisi lingkungan rumah pasien cukup
tenang dan bersih.
G. Status Kesehatan
Status kesehatan umum selama lima tahun yang lalu :
Pasien mengatakan lima tahun belakangan ini pasien pernah 2 kali masuk
rumah sakit Sanglah, yang pertama karena pasien menderita
hipertensi dengan keluhan sakit kepala berputar-putar dan pasien di

diagnosa vertigo dan yang kedua pasien masuk rumah sakit

Ganesha karena pasien mengalami keluhan tidak nafsu makan dan
mual muntah selama 1 minggu. Pasien juga pernah pingsan ketika
akan beranjak dari kamarnya dan ingin pergi ke toilet.
Keluhan utama : nyeri akut

Provokative/paliative : saat mempunyai banyak pikiran

Quality/quantity
: seperti ditusuk- tusuk
Region
: di kepala
Scale
: 4 dari (0-10) skala yang diberikan
Time
: saat stress

Obat-obatan
NO
1.
Aspilets

NAMA OBAT

DOSIS
1xI

KETERANGAN
Setelah makan

Status Imunisasi
: tidak pernah
Alergi
: tidak ada
Obat-obatan : tidak ada
Makanan
: tidak ada
Faktor lingkungan : .tidak ada
Penyakit yang diderita : tidak ada

H. ADL/Aktivitas Hidup Sehari-hari

Indeks Katz :
Kebutuhan aktivitas harian pasien diberikan nilai A, di mana pasien
mampu mandiri dalam melakukan kegiatan sehari-hari, seperti mandi,
berpakaian, ke toilet, berpindah, kontinen BAB/BAK, dan makan.
BB
: 48 kg
TL/TB
: 48 cm/160 cm
IMT
: kg BB = 48 kg = 18,75 (BB normal : 18,5-24,9)
(TB)2 (1.6)2

Vital sign

: S : 37 0C

Nadi: 80x/mnt

Respirasi :

20x/mnt
Tekanan darah: Tidur : 150/90 mmHg,Duduk : 130/90 mmHg,Berdiri :
130/90 mmHg
I. Pemenuhan Kebutuhan Sehari-hari
Oksigenasi
:
Saat pengkajian pasien mengatakan tidak mengalami masalah dalam
bernafas. Pasien tidak sesak dan tidak batuk. Tidak ada retraksi otot dada.
RR : 20x/menit
Cairan dan elektrolit :
Saat pengkajian pasien mengatakan biasa minum 5 gelas (200 cc) setiap
hari. Pasien tidak mengonsumsi kopi setelah menderita hipertensi.
Nutrisi :
Saat pengkajian pasien mengatakan biasa makan 3x sehari dan habis.
Makanan yang biasa di makan adalah sayur, lauk dan nasi. Pasien sudah
mengurangi konsumsi makanan yang mengandung garam dan mengurangi
konsumsi daging. Pasien tidak mengalami mual dan tidak muntah.
Eleminasi :
Saat pengkajian pasien mengatakan tidak mengaami gangguan BAB,
pasien biasa BAB 1x sehari pada pagi hari, dengan konsistensi feses
lembek, warna kuning kecoklatan dan bau khas feses.
Aktivitas :
Saat pengkajian pasien mengatakan pasien tidak mengalami kesulitan saat
beraktivitas sehari-hari. Pasien biasa menyapu halaman setiap hari, pasien
hanya diam di rumah saja, semenjak sakit pasien sudah tidak bekerja lagi
sebagai petani. Pasien mengeluh lemas.
Istirahat dan tidur :
Saat pengkajian pasien mengatakan biasa tidur malam pukul 23.00 Wita
dan bangun pagi pukul 06.00 Wita. Pasien mengatakan terkadang susah
tertidur dan tidur pukul 24.00 Wita.
Personal hygiene :
Saat pengkajian pasien mengatakan pasien biasa mandi 2x sehari.
Seksual :

Pasien telah berusia lanjut maka pasien tidak pernah melakukan hubungan
sosial selain istri pasien telah meninggal dunia.
Rekreasi :
Pasien tidak pernah berekreasi, pasien hanya diam di rumah saja bersama
anak dan cucu.
Psikologis
-

Persepsi klien :

pasien

memahami

bahwa

penyakit

yang

dideritanya mungkin karena faktor usia yang tidak muda lagi.

-

Konsep diri

: pasien tidak merasa rendah diri dengan kondisinya

sekarang yang semakin tua

-

Emosi

: pasien mengatakan jarang marah-marah, selalu

tenang dalam bersikap.

-

Adaptasi

: pasien mampu beradaptasi dengan keluarganya,

tetangga disekitarnya dan orang-orang yang baru dikenalnya.

-

Mekanisme pertahanan diri : bila mengalami suatu masalah selalu

berdoa kepada Tuhan YME, dan membicarakan dengan keluarganya.

J. Tinjauan Sistem
Keadaan Umum
Tingkat Kesadaran
GCS
Tanda-tanda vital

: Baik
: Compos Mentis
: E4V5M6
: Pulse : 80 x/menit

RR :20x/menit

Tensi :

130/90mmHg
Pemeriksaan fisik
1. Kepala : tidak ada lesi, rambut berwarna putih, simetris, tidak ada
benjolan.
2. Mata-Telinga-Hidung :
a. Penglihatan
:
b. Pendengaran
:
c. Hidung, Pembau :
d. Leher
:.
3. Dada dan punggung :
a. Paru paru
:
b. Jantung
: Reguler/irreguler, suhu
akral ..................................................
4. Abdomen dan pinggang :

a. Sistem pencernaan,
status : ......................................................................................
b. Sistem Genetaurinariue
: .......................................................................................
5. Ekstremitas atas dan bawah
: .......................................................................................
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6. Sistem immune
: ....................................................................................................
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7. Genetalia

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

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8.

Reproduksi
: ....................................................................................................
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9. Persarafan

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

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10. Pengecapan

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

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K. Hasil pengkajian kognitif dan mental
1. Short Portable Mental Status Questionaire (SPMSQ) :
Berdasarkan dari penilaian yang telah dilakukan kepada pasien, pasien
memiliki kesalahan sebanyak 2. Maka penialian SPMSQ pada pasien yaitu
pasien memiliki fungsi intelektual yang utuh.
2. Mini Mental State Exam (MMSE) :

Setelah dilakukan MMSE maka nilai yang didapatkan oleh pasien, yaitu
22, di mana nilai 22 masuk ke dalam kategori kemungkinan gangguan
kognitif.
3. Inventaris Depresi GDS short from :
Setelah dilakuakn penilaian GDS, maka skor yang diperoleh pasien yaitu
7, di mana masuk dalam kategori kemungkinan depresi.
L. Data Penunjang
1. Laboratorium
2. Radiologi
3. EKG
4. USG
5. CT-Scan
6. Obat obatan

::::::-

II. DIAGNOSA KEPERAWATAN

A. Analisa Data
NO
1

DATA (SIGN/SYMPTOM)
2

INTERPRETASI (ETIOLOGI)
3

MASALAH (PROBLEM)
4

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B. Diagnosa Keperawatan :

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III. INTERVENSI
A. Prioritas Diagnosa
1. ........................................................................................................................
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B. Rencana Keperawatan
DIAGNOSA
KEP.

TUJUAN

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INTERVENSI

RASIONAL

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IV. IMPLEMENTASI
HARI/
TANGGAL
/JAM

NO
DX

IMPLEMENTASI

EVALUASI

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V. CATATAN PERKEMBANGAN dan EVALUASI

NO

HARI/TGL/JAM

NO

PERKEMBANGAN

DX
3

KEPERAWATAN/EVALUASI
4
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TTD
5

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

Mengetahui

Denpasar, 21

November 2013
Pembimbing Praktek

Mahasiswa

I Putu Arnawa
NIP.
NIM.P07120011026
Ni Putu Intan
Liswandari
NIM.P071200
11027

Mengetahui
Pembimbing Akademik

NIP.