LAPORAN KASUS
ASUHAN KEPERAWATAN GERONTIK
I. IDENTITAS
a. Nama : _______________________________________
b. Jenis Kelamin : _______________________________________
c. Umur : _______________________________________
d. Agama : _______________________________________
e. Status Perkawinan : _______________________________________
f. Pendidikan Terakhir : _______________________________________
g. Pekerjaan : _______________________________________
h. Alamat rumah : _______________________________________
Pola Minum
___________________________________________________________
___________________________________________________________
Pola Tidur
___________________________________________________________
___________________________________________________________
Aktivitas Sehari-hari
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Rekreasi
___________________________________________________________
___________________________________________________________
b. Psikologis
Keadaan Emosi
___________________________________________________________
___________________________________________________________
___________________________________________________________
c. Sosial
Dukungan Keluarga
___________________________________________________________
___________________________________________________________
d. Spiritual/kultural
Pelaksanaan Ibadah
___________________________________________________________
___________________________________________________________
e. Pemeriksaan fisik
Tanda Vital
1) Keadaan Umum :_____________________________________
2) Kesadaran :_____________________________________
Kebersihan Perorangan
1) Kepala
- Rambut : _________________________________________
_________________________________________
- Mata : _________________________________________
_________________________________________
- Hidung : _________________________________________
- Mulut : _________________________________________
: _________________________________________
- Telinga : _________________________________________
: _________________________________________
2) Leher
________________________________________________________
________________________________________________________
3) Dada/Thorax
- Paru
Insp : _________________________________________
Palp : _________________________________________
Perk : _________________________________________
Ausk : _________________________________________
- Jantung
Insp : _________________________________________
Palp : _________________________________________
Perk : _________________________________________
Ausk : _________________________________________
4) Abdomen
Insp : _________________________________________
Palp : _________________________________________
Perk : _________________________________________
Ausk : _________________________________________
5) Muskuloskeletal
Kekuatan Otot :
________________________________________________________
________________________________________________________
6) Keadaan Lingkungan
________________________________________________________
________________________________________________________
V. INFORMASI PENUNJANG
Diagnosa Medis
______________________________________________________________
______________________________________________________________
Laboratorium
______________________________________________________________
______________________________________________________________
Terapi Medis
Obat-obatan
Obat Dosis Frekuensi
HARI/TANGGAL :
TEMPAT DINAS :
ANALISA DATA