UNIVERSITAS MUHAMMADIYAH PONOROGO

FAKULTAS ILMU KESEHATAN

Jl. Budi Utomo No 10 Telp. (0352)487662 Ponorogo

FORMAT ASUHAN KEPERAWATAN

PADA LANJUT USIA

Nama Mahasiswa : ___________________________________

NIM : ___________________________________

A. PENGKAJIAN
I. IDENTITAS
1. Lansia
Nama : ____________________________________________
Alamat : ____________________________________________
Jenis Kelamin : ____________________________________________
Umur : ____________________________________________
Status : ____________________________________________
Agama : ____________________________________________
Suku : ____________________________________________
Riwayat Pendidikan : ____________________________________________
Riwayat Pekerjaan : ____________________________________________
Sumber Pendapatan : ____________________________________________
Tempat tinggal sekarang : ____________________________________________
Lama Tinggal : ____________________________________________

2. Penanggung jawab
Nama : ____________________________________________
Alamat : ____________________________________________
Hubungan dengan lansia : ____________________________________________
No Telepon : ____________________________________________

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II. RIWAYAT KESEHATAN
A. Status Kesehatan Saat Ini
1. Keluhan yang dirasakan saat ini : _____________________________________
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2. Faktor Pencetus : __________________________________________________
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3. Waktu timbulnya keluhan : __________________________________________
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4. Kondisi yang memperingan dan memperberat keluhan : __________________
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5. Upaya yang telah dilakukan : ________________________________________
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B. Masalah Kesehatan Kronis (format terlampir)

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C. Riwayat Kesehatan Masa Lalu

1. Penyakit yang pernah diderita : _______________________________________
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2. Riwayat jatuh/kecelakaan : __________________________________________
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3. Riwayat dirawat di rumah sakit : ______________________________________
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 4. Riwayat pemakaian obat : ___________________________________________
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5. Riwayat alergi (obat, makanan, debu, dan lain-lain) : ______________________
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D. Riwayat Kesehatan Keluarga

1. Penyakit yang pernah diderita keluarga : ________________________________
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2. Genogram :

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III. STATUS FISIOLOGIS
A. Pola Kebiasaan Sehari-Hari
1. Nutrisi
a. Frekuensi makan : _______________________________________________
b. Jenis makanan : _________________________________________________
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c. Kebiasaan makan : ______________________________________________
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d. Makanan yang disukai : __________________________________________
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e. Makanan tidak disukai : __________________________________________
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f. Pantangan makan : ______________________________________________
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g. Keluhan makan : ________________________________________________
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2. Eliminasi
a. Frekuensi
- BAK : _____________________________________________________
- BAB : _____________________________________________________
b. Konsistensi
- BAK : _____________________________________________________
- BAB : _____________________________________________________

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 c. Kebiasaan
- BAK : _____________________________________________________
- BAB : _____________________________________________________
d. Keluhan
- BAK : _____________________________________________________
- BAB : _____________________________________________________
e. Riwayat pemakaian obat (diuretic, laxative/pencahar dll)
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3. Istirahat/Tidur :
a. Frekuensi tidur : _________________________________________________
b. Lama Tidur :____________________________________________________
c. Kebiasaan Tidur : _______________________________________________
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d. Keluhan Tidur :__________________________________________________
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e. Riwayat penggunaan obat tidur : _____________________________________
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4. Aktifitas Sehari-hari :
a. Kegiatan yang dilakukan sehari-hari : _________________________________
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b. Kegiatan olahraga : _______________________________________________
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 c. Kebiasaan mengisi waktu luang : ____________________________________
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d. Kemandirian dalam beraktifitas (format terlampir)
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e. Keseimbangan (format terlampir)
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5. Personal Higiene
a. Kebiasaan mandi : ________________________________________________
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b. Kebiasaan gosok gigi : _____________________________________________
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c. Kebiasaan cuci rambut : ___________________________________________
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d. Kebiasaan gunting kuku : __________________________________________
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6. Reproduksi dan Seksual

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B. Pemeriksaan Fisik
1. Tanda-Tanda Vital dan Status Gizi
- Suhu : ____________________________________________
- Tekanan Darah : ____________________________________________
- Nadi : ____________________________________________
- Respirasi : ____________________________________________
- Berat badan : ____________________________________________
- Tinggi badan : ____________________________________________
- IMT : ___________________________________________
2. Kepala : _____________________________________________________________
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3. Mata : _______________________________________________________________
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4. Hidung :
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5. Mulut, Gigi dan Tenggorokan : ____________________________________________
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6. Telinga : _____________________________________________________________
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7. Leher : _______________________________________________________________
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8. Dada : _______________________________________________________________
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 9. Payudara : ___________________________________________________________
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10. Abdomen : ___________________________________________________________
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11. Genetalia : ___________________________________________________________
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12. Ekstremitas : _________________________________________________________
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13. Integumen : __________________________________________________________
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IV. STATUS KOGNITIF

A. Fungsi Kognitif (format terlampir) : ________________________________________
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V. STATUS PSIKOSOSIAL DAN SPIRITUAL

A. Psikologis
1. Persepsi Lansia terhadap proses menua
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2. Harapan Lansia terhadap proses menua
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3. Status Depresi (format terlampir) : _____________________________________

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 B. Sosial
1. Dukungan Keluarga (format terlampir) : _________________________________
2. Pola Komunikasi dan Interaksi lansia :___________________________________
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C. Spiritual
1. Kegiatan Keagamaan : _______________________________________________
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2. Konsep keyakinan tentang kematian : ___________________________________
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3. Upaya untuk meningkatkan spiritualitas : ________________________________
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VI PENGKAJIAN LINGKUNGAN TEMPAT TINGGAL

A. Kebersihan dan Kerapihan ruangan : _______________________________________
_____________________________________________________________________
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B. Penerangan : _________________________________________________________
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C. Sirkulasi Udara : _______________________________________________________
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D. Keadaan kamar mandi dan WC : __________________________________________
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 E. Pembuangan air kotor : _________________________________________________
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F. Sumber air minum : ____________________________________________________
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G. Pembuangan sampah : __________________________________________________
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H. Sumber Pencemaran : __________________________________________________
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VII. INFORMASI TAMBAHAN

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(______________________)

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B. ANALISA DATA
NO DATA PROBLEM ETIOLOGI

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(______________________)

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C. DAFTAR DIAGNOSA
NO TANGGAL DIAGNOSA KEPERAWATAN

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(_______________________________)

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D. RENCANA KEPERAWATAN

NO TUJUAN KRITERIA INTERVENSI RASIONAL

HASIL

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(_______________________________)

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E. TINDAKAN KEPERAWATAN

NO WAKTU IMPLEMENTASI DAN RESPON TTD

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F. EVALUASI

NO WAKTU CATATAN PERKEMBANGAN TTD

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