PRAKTEK PROFESI KEPERAWATAN GERONTIK

FAKULTAS KEPERAWATAN UNAND 2018

________________________________________________________________________
LAPORAN KASUS
ASUHAN KEPERAWATAN GERONTIK

Nama Panti : _______________________________________

Alamat Panti : _______________________________________
Tanggal Masuk : _______________________________________
No. Register : _______________________________________

I. IDENTITAS
a. Nama : _______________________________________
b. Jenis Kelamin : _______________________________________
c. Umur : _______________________________________
d. Agama : _______________________________________
e. Status Perkawinan : _______________________________________
f. Pendidikan Terakhir : _______________________________________
g. Pekerjaan : _______________________________________
h. Alamat rumah : _______________________________________

II. ALASAN KUNJUNGAN KE PANTI

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III. RIWAYAT KESEHATAN
a. Masalah kesehatan yang pernah dialami dan dirasakan saat ini:
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Intan Nia Soleha, S.Kep

1841312035
 PRAKTEK PROFESI KEPERAWATAN GERONTIK
FAKULTAS KEPERAWATAN UNAND 2018
________________________________________________________________________
b. Masalah kesehatan keluarga/keturunan
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IV. KEBIASAAN SEHARI-HARI
a. Biologis
Pola Makan
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Pola Minum
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Pola Tidur
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Pola Eliminasi (BAK & BAB)

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Aktivitas Sehari-hari
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Rekreasi
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Intan Nia Soleha, S.Kep

1841312035
 PRAKTEK PROFESI KEPERAWATAN GERONTIK
FAKULTAS KEPERAWATAN UNAND 2018
________________________________________________________________________
b. Psikologis
Keadaan Emosi
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c. Sosial
Dukungan Keluarga
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Hubungan Antar Keluarga

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Hubungan dengan Orang Lain

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d. Spiritual/kultural
Pelaksanaan Ibadah
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Keyakinan Tentang Kesehatan

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e. Pemeriksaan fisik
Tanda Vital
1) Keadaan Umum :_____________________________________
2) Kesadaran :_____________________________________

Intan Nia Soleha, S.Kep

1841312035
 PRAKTEK PROFESI KEPERAWATAN GERONTIK
FAKULTAS KEPERAWATAN UNAND 2018
________________________________________________________________________
o
3) Suhu : C
4) Nadi : x/i
5) Tekanan Darah : mmHg
6) Pernafasan : x/i
7) Tinggi Badan : cm
8) Berat Badan : kg

Kebersihan Perorangan
1) Kepala
- Rambut : _________________________________________
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- Mata : _________________________________________
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- Hidung : _________________________________________
- Mulut : _________________________________________
: _________________________________________
- Telinga : _________________________________________
: _________________________________________
2) Leher
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3) Dada/Thorax
- Paru
Insp : _________________________________________
Palp : _________________________________________
Perk : _________________________________________
Ausk : _________________________________________
- Jantung
Insp : _________________________________________
Palp : _________________________________________
Perk : _________________________________________
Ausk : _________________________________________

Intan Nia Soleha, S.Kep

1841312035
 PRAKTEK PROFESI KEPERAWATAN GERONTIK
FAKULTAS KEPERAWATAN UNAND 2018
________________________________________________________________________
4) Abdomen
Insp : _________________________________________
Palp : _________________________________________
Perk : _________________________________________
Ausk : _________________________________________
5) Muskuloskeletal
Kekuatan Otot :

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6) Keadaan Lingkungan
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V. INFORMASI PENUNJANG
Diagnosa Medis
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Laboratorium
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Terapi Medis
Obat-obatan
Obat Dosis Frekuensi

ANALISA DATA
No Data Masalah Keperawatan

Intan Nia Soleha, S.Kep

1841312035
 PRAKTEK PROFESI KEPERAWATAN GERONTIK
FAKULTAS KEPERAWATAN UNAND 2018
________________________________________________________________________

NANDA, NOC, NIC

No Diagnosa Keperawatan NOC NIC

Intan Nia Soleha, S.Kep

1841312035
 PRAKTEK PROFESI KEPERAWATAN GERONTIK
FAKULTAS KEPERAWATAN UNAND 2018
________________________________________________________________________

NANDA, NOC, NIC

No Diagnosa Keperawatan NOC NIC

Intan Nia Soleha, S.Kep

1841312035
 PRAKTEK PROFESI KEPERAWATAN GERONTIK
FAKULTAS KEPERAWATAN UNAND 2018
________________________________________________________________________

NANDA, NOC, NIC

No Diagnosa Keperawatan NOC NIC

Intan Nia Soleha, S.Kep

1841312035
 PRAKTEK PROFESI KEPERAWATAN GERONTIK
FAKULTAS KEPERAWATAN UNAND 2018
________________________________________________________________________

Intan Nia Soleha, S.Kep

1841312035