UNIVERSITAS MUHAMMADIYAH PONOROGO

FAKULTAS ILMU KESEHATAN

Jl. Budi Utomo No 10 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 : ____________________________________________

fik-ump/format_askep_lansia/L3 1
II. RIWAYAT KESEHATAN
A. Status Kesehatan Saat Ini
1. Keluhan yang dirasakan saat ini : _____________________________________
________________________________________________________________
________________________________________________________________
2. Faktor Pencetus : __________________________________________________
________________________________________________________________
________________________________________________________________
3. Waktu timbulnya keluhan : __________________________________________
________________________________________________________________
________________________________________________________________
4. Kondisi yang memperingan dan memperberat keluhan : __________________
________________________________________________________________
________________________________________________________________
5. Upaya yang telah dilakukan : ________________________________________
________________________________________________________________
________________________________________________________________

B. Masalah Kesehatan Kronis (format terlampir)

___________________________________________________________________

C. Riwayat Kesehatan Masa Lalu

1. Penyakit yang pernah diderita : _______________________________________
_________________________________________________________________
_________________________________________________________________
2. Riwayat jatuh/kecelakaan : __________________________________________
_________________________________________________________________
_________________________________________________________________
3. Riwayat dirawat di rumah sakit : ______________________________________
_________________________________________________________________
_________________________________________________________________

fik-ump/format_askep_lansia/L3 2
 4. Riwayat pemakaian obat : ___________________________________________
_________________________________________________________________
_________________________________________________________________
5. Riwayat alergi (obat, makanan, debu, dan lain-lain) : ______________________
_________________________________________________________________
_________________________________________________________________

D. Riwayat Kesehatan Keluarga

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

fik-ump/format_askep_lansia/L3 3
III. STATUS FISIOLOGIS
A. Pola Kebiasaan Sehari-Hari
1. Nutrisi
a. Frekuensi makan : _______________________________________________
b. Jenis makanan : _________________________________________________
______________________________________________________________
______________________________________________________________
c. Kebiasaan makan : ______________________________________________
______________________________________________________________
______________________________________________________________
d. Makanan yang disukai : __________________________________________
______________________________________________________________
______________________________________________________________
e. Makanan tidak disukai : __________________________________________
______________________________________________________________
______________________________________________________________
f. Pantangan makan : ______________________________________________
______________________________________________________________
______________________________________________________________
g. Keluhan makan : ________________________________________________
______________________________________________________________
______________________________________________________________

2. Eliminasi
a. Frekuensi
- BAK : _____________________________________________________
- BAB : _____________________________________________________
b. Konsistensi
- BAK : _____________________________________________________
- BAB : _____________________________________________________

fik-ump/format_askep_lansia/L3 4
 c. Kebiasaan
- BAK : _____________________________________________________
- BAB : _____________________________________________________
d. Keluhan
- BAK : _____________________________________________________
- BAB : _____________________________________________________
e. Riwayat pemakaian obat (diuretic, laxative/pencahar dll)
______________________________________________________________
______________________________________________________________
______________________________________________________________

3. Istirahat/Tidur :
a. Frekuensi tidur : _________________________________________________
b. Lama Tidur :____________________________________________________
c. Kebiasaan Tidur : _______________________________________________
_______________________________________________________________
_______________________________________________________________
d. Keluhan Tidur :__________________________________________________
_______________________________________________________________
_______________________________________________________________
e. Riwayat penggunaan obat tidur : _____________________________________
_______________________________________________________________
_______________________________________________________________

4. Aktifitas Sehari-hari :
a. Kegiatan yang dilakukan sehari-hari : _________________________________
_______________________________________________________________
_______________________________________________________________
b. Kegiatan olahraga : _______________________________________________
_______________________________________________________________
_______________________________________________________________

fik-ump/format_askep_lansia/L3 5
 c. Kebiasaan mengisi waktu luang : ____________________________________
_______________________________________________________________
_______________________________________________________________
d. Kemandirian dalam beraktifitas (format terlampir)
_______________________________________________________________
_______________________________________________________________
e. Keseimbangan (format terlampir)
_______________________________________________________________
_______________________________________________________________

5. Personal Higiene
a. Kebiasaan mandi : ________________________________________________
_______________________________________________________________
_______________________________________________________________
b. Kebiasaan gosok gigi : _____________________________________________
_______________________________________________________________
_______________________________________________________________
c. Kebiasaan cuci rambut : ___________________________________________
_______________________________________________________________
_______________________________________________________________
d. Kebiasaan gunting kuku : __________________________________________
_______________________________________________________________
_______________________________________________________________

6. Reproduksi dan Seksual

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

fik-ump/format_askep_lansia/L3 6
B. Pemeriksaan Fisik
1. Tanda-Tanda Vital dan Status Gizi
- Suhu : ____________________________________________
- Tekanan Darah : ____________________________________________
- Nadi : ____________________________________________
- Respirasi : ____________________________________________
- Berat badan : ____________________________________________
- Tinggi badan : ____________________________________________
- IMT : ___________________________________________
2. Kepala : _____________________________________________________________
____________________________________________________________________
____________________________________________________________________
3. Mata : _______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
4. Hidung :
______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
5. Mulut, Gigi dan Tenggorokan : ____________________________________________
_____________________________________________________________________
_____________________________________________________________________
6. Telinga : _____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
7. Leher : _______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
8. Dada : _______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

fik-ump/format_askep_lansia/L3 7
 9. Payudara : ___________________________________________________________
____________________________________________________________________
____________________________________________________________________
10. Abdomen : ___________________________________________________________
____________________________________________________________________
____________________________________________________________________
11. Genetalia : ___________________________________________________________
____________________________________________________________________
____________________________________________________________________
12. Ekstremitas : _________________________________________________________
____________________________________________________________________
____________________________________________________________________
13. Integumen : __________________________________________________________
____________________________________________________________________
____________________________________________________________________

IV. STATUS KOGNITIF

A. Fungsi Kognitif (format terlampir) : ________________________________________
_____________________________________________________________________

V. STATUS PSIKOSOSIAL DAN SPIRITUAL

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

fik-ump/format_askep_lansia/L3 8
 B. Sosial
1. Dukungan Keluarga (format terlampir) : _________________________________
2. Pola Komunikasi dan Interaksi lansia :___________________________________
_________________________________________________________________
_________________________________________________________________

C. Spiritual
1. Kegiatan Keagamaan : _______________________________________________
__________________________________________________________________
__________________________________________________________________
2. Konsep keyakinan tentang kematian : ___________________________________
__________________________________________________________________
__________________________________________________________________
3. Upaya untuk meningkatkan spiritualitas : ________________________________
__________________________________________________________________
__________________________________________________________________

VI PENGKAJIAN LINGKUNGAN TEMPAT TINGGAL

A. Kebersihan dan Kerapihan ruangan : _______________________________________
_____________________________________________________________________
_____________________________________________________________________
B. Penerangan : _________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
C. Sirkulasi Udara : _______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
D. Keadaan kamar mandi dan WC : __________________________________________
_____________________________________________________________________
_____________________________________________________________________

fik-ump/format_askep_lansia/L3 9
 E. Pembuangan air kotor : _________________________________________________
_____________________________________________________________________
_____________________________________________________________________
F. Sumber air minum : ____________________________________________________
_____________________________________________________________________
_____________________________________________________________________
G. Pembuangan sampah : __________________________________________________
_____________________________________________________________________
_____________________________________________________________________
H. Sumber Pencemaran : __________________________________________________
_____________________________________________________________________
_____________________________________________________________________

VII. INFORMASI TAMBAHAN

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

______________,__________________

(______________________)

fik-ump/format_askep_lansia/L3 10
B. ANALISA DATA
NO DATA PROBLEM ETIOLOGI

______________,__________________

(______________________)

fik-ump/format_askep_lansia/L3 11
C. DAFTAR DIAGNOSA
NO TANGGAL DIAGNOSA KEPERAWATAN

______________,__________________

(_______________________________)

fik-ump/format_askep_lansia/L3 12
D. RENCANA KEPERAWATAN

NO TUJUAN KRITERIA INTERVENSI RASIONAL

HASIL

______________,__________________

(_______________________________)

fik-ump/format_askep_lansia/L3 13
E. TINDAKAN KEPERAWATAN

NO WAKTU IMPLEMENTASI DAN RESPON TTD

fik-ump/format_askep_lansia/L3 14
F. EVALUASI

NO WAKTU CATATAN PERKEMBANGAN TTD

fik-ump/format_askep_lansia/L3 15