Format Pengkajian Lansia

FORMAT PENGKAJIAN LANSIA

I.

Profil klien
A. Data Demografi
1. Nama

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

2. Status Lahir

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

3. Status Perkawinan : .......................................................................

4. Agama

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

5. Suku

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

6. Pekerjaan sblmnya : .......................................................................

7. Pekerjaan saat ini : .......................................................................
8. Keluarga terdekat : .......................................................................
B. Geografi

II.

1. Letak/lokasi

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

2. Jarak dgn pel.kes

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

Riwayat Psikososial
A. Lingkungan Tempat Tingga (Panti)
a). Perumahan
1. Kebutuhan rasa aman

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

2. Kebutuhan mobilitas

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

3. Kemudahan dikamar mandi: ....................................................................

4. Adakah teman sekamar

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

5. Jarak dgn keluarga terdkt : ....................................................................

6. Hub.dgn teman seunit

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

b). Masyarakat Lansia

Pemanfaatan sumber-sumber
1. Poliklinik

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

2. Rekreasi

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

3. Pengajian

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

4. Kebaktian

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

5. Televisi/radio

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

6. Ruangan perpustakaan/buku bacaan : .....................................................

B. Status Ekonomi
a). Sumber Dana

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

b). Penggunaan

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

C. Pekerjaan / Kegiatan
a). Yang lalu

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

b). Sekarang

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

c). Aktivitas sehari-hari

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

d). Status Kesehatan

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

Format Pengkajian Lansia

III.

Profil Keluarga
A. Keadaan Keluarga
a). Tipe keluarga

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

b). Status Keluarga

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

c). Hub.anggota klrg

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

d). Status kesehatan

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

B. Hubungan Dengan Keluarga

a). Kepuasan hub. Yang lalu dgn klrg : .............................................................
b). Hub. Saat ini
IV.

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

Riwayat Kesehatan
A. Status Kesehatan
a). Persepsi terhadap status kesehatan
1). Sekarang : ............................................................................................
2). Yang lalu : ............................................................................................
b). Status kesehatan masa lalu
1). Penyakit menular
: ......................................................................
2). Perawatan di RS
: ......................................................................
3). Kecelakaan termasuk jatuh: .....................................................................
4). Alergi obat
: ......................................................................
5). Masalah kesehatan lainnya: .....................................................................
B. Faktor Resiko Terjadinya Masalah Kesehatan
a). Merokok

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

- Masa Lalu

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

- Sekarang

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

b). Minum kopi/teh : ............................................................................................

c). Penggunaan obat-obatan : ...............................................................................
- Berdasarkan resep
: ..................................................................................
- Adiksi obat
: ..................................................................................
- Lain-lain
: ..................................................................................
C. Kegiatan Peningkatan Kesehatan
a). Pemeriksaan Kesehatan
: ......................................................................
b). Pola Aktivitas
: ......................................................................

Format Pengkajian Lansia

1. Tertarik dgn aktivitas

: ......................................................................
2. Mengikuti program latihan
: ......................................................................
3. Penggunaan waktu senggang : ..................................................................
4. Tingkat kemandirian
: ......................................................................
5. Kepuasan terhadap kemandirian : .............................................................
6. Pola aktivitas selama 24 jam : ...................................................................
7. Oksigenisasi
: ..................................................................................
- Efek aktivitas terhadap pernapasan
: ..............................................
- Masalah/gangguan pernapasan
: ..............................................
- Alat Bantu pernapasan
: ..............................................
- Batuk/sputum
: ..............................................
- Obat-obatan
: ..............................................
8. Mobilitas
: ..............................................................................................
- Berjalan
: ......................................................................
- Alat Bantu berjalan
: ......................................................................
- Alat Bantu pd persendian
: ..........................................................
- Saat bergerak / istirahat
: ..........................................................
- Faktor yang mempengaruhi ketidaknyamanan :

9. Fasilitas lingkungan tempat tinggal untuk beraktivitas :

10. Pola istirahat dan tidur

- Jumlah jam tidur malam hari
: ..............................................
- Frekwensi bangun malam hari
: ..............................................

Format Pengkajian Lansia

- Kenyamanan saat bangun tidur

: ..............................................
- Bantuan untuk bangun
: ..............................................
- Kebisingan/penerangan lampu
: ..............................................
11. Imobilitas
- Tingkat imobilitas
: ......................................................................
- Penyebab
: ......................................................................
- Aktif dan pasif exercise selama mobilitas
: ..................................
c). Nutrisi
1. Jumlah makan yang dikonsumsi sehari/seminggu
: ..................................
2. Sayur / buah
: ..................................................................................
3. Kebiasaan makan
: ..................................................................................
4. Vitamin & mineral
: ..................................................................................
5. Intake cairan
: ..................................................................................
6. Perubahan rasa
: ..................................................................................
7. Perubahan BB
: ..................................................................................
d). Eliminasi
1. BAB
: ..............................................................................................
2. BAK
: ..............................................................................................
e). Perlindungan diri
1. Respon terhadap suhu/lingkungan penangguhan
: ..................................
2. Perlindungan perawatan kulit
: ..........................................................
3. Perawatan kuku
: ..................................................................................
4. Perawatan rambut
: ..................................................................................

Format Pengkajian Lansia

f). Fungsi sensorik pendengaran

1. Masalah pendengaran : ..............................................................................
2. Alat Bantu pendengaran : ..........................................................................
g) Fungsi sensorik penglihatan
1. Masalah penglihatan : ...............................................................................
2. Alat Bantu : ..............................................................................................
i). Fungsi sensorik perabaan
1. Adekuat : ...................................................................................................
2. Sensitivitas nyeri : .....................................................................................
j). Fungsi sensorik penciuman
1. Adekuat : ...................................................................................................
2. Respon terhadap debu : .............................................................................
3. Alergi : ......................................................................................................
k). Fungsi sensorik perasa
1. Adekuat terhadap manis,asin : ..................................................................
2. Perawatan mulut : ......................................................................................
3. Penggunaan alat bantu makan : .................................................................
l). Status mental
1. Kognitif : ...................................................................................................
2. Mood (suasana hati) : ................................................................................
3. Pola komunikasi : ......................................................................................
4. Self body image : ......................................................................................
5. Seksualitas : ...............................................................................................
- Persepsi terhadap jenis kelamin : ............................................................
- Hubungan dgn teman sejenis : ................................................................
- Hubungan dgn lawan jenis : ...................................................................
- Aktivitas seksual / perubahan / masalah : ...............................................

V.

Pengkajian Fisik
a. Keadaan umum klien : ...........................................................................................
b. Ukuran tubuh : ......................................................................................................
c. Tanda vital : Td,N.Sb.R.: ......................................................................................
d. Status mental : .......................................................................................................
e. Sensitivitas kulit : ..................................................................................................
f. Kepela / leher : ......................................................................................................
g. Penglihatan : .........................................................................................................
h. Pendengaran : .......................................................................................................

Format Pengkajian Lansia

i. Hidung : ...............................................................................................................
j. Mulut : ...................................................................................................................
k. Bunyi dada & pernapasan : ...................................................................................
l. Abdomen : .............................................................................................................
m. Anus : ..................................................................................................................
n. Pembuluh darah perifer : .......................................................................................
o. Tangan & kaki : ...................................................................................................
p. Muskuloskeletal : ..................................................................................................

VI.

Pengkajian Fungsional
a. Mandi : ..................................................................................................................
b. Pakaian : ...............................................................................................................
c. Toilet : ..................................................................................................................
d. Berpindah : ............................................................................................................
e. BAB / BAK : .........................................................................................................
f. Makan / minum : ...................................................................................................
g. Tingkat mobilitas : ...............................................................................................
h. Pola prilaku : .........................................................................................................
i. Kebutuhan komunikasi : ........................................................................................