FORMAT RESUME KEPERAWATAN GERONTIK

PROGRAM STUDI PROFESI KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN MUHAMMADIYAH SAMARINDA
ASUHAN KEPERAWATAN GERONTIK
Jl. Ir. H. Juanda No. 15 Samarinda
Telpon / Fax (0541-748511)

Tanggal Pengkajian
A. Karakteristik Demografi
1. Identitas Diri Klien
Nama Lengkap :. Pendidikan terakhir :.
Tempat / Tgl lahir :. Diagnosa Medis
. (bila ada) :.
Jenis Kelamin :. Alamat :.
Umur :. .
Status Perkawinan :. ..
Agama :. ..
Suku Bangsa :.
..
..

2. Keluarga atau orang lain yang penting/dekat yang dapat dihubungi :

Nama : .
Alamat : ..
No. Telp. : ..............................................
Hub. dengan klien : ..............................................
3. Riwayat Pekerjaan dan Status Ekonomi
Pekerjaan saat ini : ..........................................................................................
Pekerjaan sebelumnya: ..........................................................................................
Sumber pendapatan : ..........................................................................................
Kecukupan pendapatan : ..........................................................................................
4. Aktivitas Rekreasi
Hobi : ..........................................................................
............................
Bepergian/wisata : ..........................................................................
............................
Keanggotaan
organisasi: ..............................................................................................
Lain-lain
: ......................................................................................................

5. Riwayat Keluarga
a. Saudara kandung
Nama Keadaan saat ini Keterangan
1.
2.
3.
 4.
5.

b. Riwayat kematian dalam keluarga (1 tahun terakhir) :

Nama : ......................................................................................
..................
Umur : ......................................................................................
..................
Penyebab
kematian: ....................................................................................................

c. Kunjungan
keluarga: ........................................................................................................

B. Pola Kebiasaan Sehari-hari

1. Nutrisi



2. Eliminasi
a. BAK



b. BAB



3. Personal Higiene



4. Istirahat dan Tidur



5. Kebiasaan mengisi waktu luang



6. Kebiasaan yang mempengaruhi kesehatan (jenis/frekuensi/jumlah/lama pakai):



7. Uraian kronologis kegiatan sehari-hari
Jenis kegiatan Lama waktu untuk setiap kegiatan
1.
 2.
3.

C. Status Kesehatan
1. Status Kesehatan Saat Ini
a. Keluhan utama dalam 1 tahun
terakhir ...........................................................................................................................
........................................................................................................................................
.............
b. Gejala yang
dirasakan ........................................................................................................................
........................................................................................................................................
...............
c. Faktor
pencetus .........................................................................................................................
........................................................................................................................................
...............
d. Timbulnya keluhan : ( ) Mendadak ( ) Bertahap
e. Waktu mulai timbulnya
keluhan ..........................................................................................................................
........................................................................................................................................
..............
f. Upaya mengatasi :
Pergi ke RS/klinik pengobatan/dokter praktik:........................................................
Pergi ke bidan/perawat :...........................................................................................
Mengonsumsi obat-obatan sendiri :..........................................................................
Mengonsumsi obat-obatan tradisional :....................................................................
Lain-lain :.................................................................................................................

2. Riwayat Kesehatan masa lalu

a. Penyakit yang pernah diderita :

b. Riwayat alergi (obat, makanan, binatang, debu, dan lain-
lain) ................................................................................................................................
........................................................................................................................................
........
c. Riwayat
kecelakaan .....................................................................................................................
........................................................................................................................................
...................
d. Riwayat dirawat di rumah
sakit ................................................................................................................................
........................................................................................................................................
........
e. Riwayat pemakaian
obat ................................................................................................................................
........................................................................................................................................
........
 3. Pengkajian/pemeriksaan Fisik (Observasi, pengukuran, auskultasi, perkusi, dan
palpasi)
a. Keadaan umum (TTV) :
TD : Respirasi :
Nadi : Temperatur :
b. BB/TB :......./....... maka IMT saat ini =........... KET. :...............
c. Rambut ...........................................................................................................
........................................................................................................................................
.............................
d. Mata : ..............................................................................................................
........................................................................................................................................
..........................
e. Telinga : ..........................................................................................................
........................................................................................................................................
..............................
f. Mulut, gigi dan
bibir : .............................................................................................................................
........................................................................................................................................
...........
g. Dada : ..............................................................................................................
........................................................................................................................................
..........................
h. Abdomen : ......................................................................................................
........................................................................................................................................
..................................
i. Kulit : ..............................................................................................................
........................................................................................................................................
..........................
j. Ekstremitas
atas : ...............................................................................................................................
........................................................................................................................................
.........
k. Ekstremitas
bawah : ...........................................................................................................................
........................................................................................................................................
.............

D. Hasil Pengkajian Khusus

1. Masalah kesehatan kronis :
.......................................................................................................................................
2. Fungsi kognitif :
.......................................................................................................................................
3. Status fungsional :
.......................................................................................................................................
4. Status psikologis (skala depresi) :
.......................................................................................................................................
5. Dukungan keluarga :
.......................................................................................................................................

E. Lingkungan Tempat Tinggal



Data Penunjang
1. Laboratorium
: ..................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.....
2. Tes Diagnosis :
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
3. Obat-obatan :
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
ANALISA DATA

No. Data Fokus Penyebab (Etiologi) Masalah (Problem)

RENCANA ASUHAN KEPERAWATAN

No Diagnosa Keperawatan Tujuan Intervensi Rasional
 IMPLEMENTASI ASUHAN KEPERAWATAN

TGL/ IMPLEMENTASI EVALUASI

WAKTU

EVALUASI ASUHAN KEPERAWATAN

DIAGNOSA
NO EVALUASI
KEPERAWATAN