FORMAT PENGKAJIAN KEPERAWATAN GERONTIK

Nama mahasiswa :
Tempat Praktek :
Tanggal Praktek :
Tanggal Pengkajian :

ASUHAN KEPERAWATAN LANSIA

A. IDENTITAS
Data Umum Pasien Penanggung Jawab

Nama : .
No RM : .
Umur : .
Agama : .
Alamat : .
Pendidikan terakhir : .
Pekerjaan terakhir : .
Tanggal masuk : .
Hub. dengan pasien ................................

B. GENOGRAM
Keterangan:

: Laki-laki meninggal : Pasien laki-laki

: Perempuan meninggal : Garis keturunan
: Laki-laki hidup : Garis perkawinan
: Perempuan hidup : Tinggal dalam 1 rumah
: Pasien perempuan

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C. Riwayat Kesehatan
1. Keluhan utama saat ini :

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2. Riwayat kesehatan keluarga :

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 3. Riwayat Alergi :

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D. Pemeriksaan Fisik
1. Keadaan Umum
2. Nyeri : Klien ( ) mengatakan,
P :.............................................................................................................................
Q :.............................................................................................................................
R :.............................................................................................................................
S :.............................................................................................................................
T :.............................................................................................................................
3. Status gizi : BB saat ini :.........kg Tb : ........cm
4. BMI : ..
Gizi cukup
Gizi lebih
Gizi kurang
5. Personal Hygiene :
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Aktivitas Mandir Tergantung

i
Mandi
Berpakaian
Ke kamar kecil
Berpindah
Kontinen
Makan

6. Sistem persepsi sensori

a. Pendengaran :
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b. Penglihatan :
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c. Pengecap/Penghidu :
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d. Peraba :
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7. Sistem pernafasan
a. Dada :
I : ....................................................................................................................
P : ....................................................................................................................
P : ....................................................................................................................
A : ....................................................................................................................
b. Frekwensi/RR : ....................................................................................................
c. Suara nafas : ....................................................................................................
8. Sistem kardiovaskuler
I : ............................................................................................................................
P : ............................................................................................................................
P : ............................................................................................................................
A : ............................................................................................................................
 Tekanan darah : ......mmHg, Nadi :....x/menit, Capillary Refill :..

9. Sistem saraf pusat

a. Kesadaran : ....................................................................................................
b. Orientasi waktu : ....................................................................................................
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c. Orientasi orang : ....................................................................................................
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10. Sistem gastrointestinal

a. Nafsu makan :
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b. Pola makan :
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c. Abdomen :
I : ....................................................................................................................
A : ....................................................................................................................
P : ....................................................................................................................
P : ....................................................................................................................
 d. BAB :
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11. Sistem musculoskeletal

a. Rentang gerak
1) Ekstremitas Atas :
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2) Ekstremitas Bawah :
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b. Kemampuan ADL :
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12. Sistem integument

a. Pressure
ulcer : ........................................................................................................
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13. Sistem reproduksi
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 14. Sistem perkemihan
a. Pola BAK : ....................................................................................................
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b. Inkontinensia : ....................................................................................................
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E. Data Penunjang
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F. Pengkajian Nervous Cranial

1. Nervous Olfaktori (penciuman / N5)
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2. N. II (Optikus)
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3. N. III (Okulomotorius)
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4. N. IV (Trochlearis)
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5. N. V (Trigeminus)
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6. N. VI (Abdusen)
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7. N. VII (Fasialis)
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8. N. VIII (Auditorius)
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9. N. IX (Glosofaringealis)
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10. N. X (Vagus)
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11. N. XI (Asesoris)
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12. N. XII (Hipoglosus)

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G. Terapi yang diberikan

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H. PSIKOSOSIAL BUDAYA DAN SPIRITUAL

1. Psikologis
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2. Sosial
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3. Budaya
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4. Spiritual
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I. ANALISA DATA DAN DIAGNOSA KEPERAWATAN

NO DATA PENYEBAB MASALAH

J. DIAGNOSA KEPERAWATAN
K. IMPLEMENTASI

Hari/ No Implementasi Respon TT

Tgl/Jam DX D
L. EVALUASI

Hari/ No. Evaluasi TTD

Tgl/Jam DX