FORMAT PENGKAJIAN ASUHAN KEPERAWATAN LANJUT USIA

I. DATA DEMOGRAFI
NAMA LANSIA :
UMUR :
ALAMAT :
JENIS KELAMIN :
JUMLAH KETURUNAN - ANAK :
- CUCU :
NAMA SUAMI/ISTRI :
UMUR :
_________________________________________________________________________

II. PENGKAJIAN :

A. Fisik

Wawancara

 Pandangan Lanjut Usia tentang kesehatannya :

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 Kegiatan yang mampu dilakukan Lanjut Usia :
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 Kebiasaan Lanjut Usia merawat diri sendiri :

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 Kekuatan fisik Lanjut Usia: otot, sendi, penglihatan dan pendengaran :

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 Kebiasaan makan, minum, istirahat/tidur, buang air besar/kecil :

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 Kebiasaan gerak badan/olah raga/senam Lanjut Usia :

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 Perubahan-perubahan fungsi tubuh yang sangat bermakna dirasakan :

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 Kebiasaan Lanjut Usia dalam memelihara kesehatan dan kebiasaan dalam
minum obat:
..................................................................................................................................
...............................................................................................................
.........................................................................................................................

 Masalah-masalah seksual yang dirasakan:

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Pemeriksaan Fisik
 Pemeriksaan dilakukan dengan cara inspeksi, palpilasi, perkusi dan auskultasi
untuk mengetahui perubahan sistem tubuh
 Pendekatan yang digunakan dalam pemeriksaan fisik, yaitu:
- Head to toe
- Sistem tubuh

1. Temperatur :
..................................................................................................................................
................................................................................................................

- Tempat pengukuran :

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2. Pulse (denyut nadi) :

 Kecepatan :
............................................................................................................................
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 Irama :
............................................................................................................................
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 Volume:
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Tempat Pengukuran :
 Apikal ...................... Radial ................

3. Respirasi (Pernafasan) :
 Kecepatan :
............................................................................................................................
..........................................................................................................
 Irama :
............................................................................................................................
..........................................................................................................

 Kedalaman :
............................................................................................................................
..........................................................................................................
 Bunyi:
............................................................................................................................
..........................................................................................................
4. Tekanan Darah :
Posisi pengukuran :
 Saat baring ..................
 Duduk ...........................
 Berdiri .........................
5. Berat dan tinggi badan terakhir :
..................................................................
6. Tingkat orientasi:
a. Waktu : …………………………………………
b. Tempat : ................................................................
c. Orang : ...............................................................

7. Memory (ingatan) : ................................................................

8. Tidur
a. Kwantitas (Lama tidur) : ...............................................................
b. Kwalitas : ...............................................................
c. Pola : ...............................................................

9. Istirahat
a. Kwantitas (Lama tidur) : ...............................................................
b. Kwalitas : ...............................................................
c. Pola : ...............................................................

10. Penyesuaian psikososial : ...............................................................

...............................................................
................................................................
Sistem Persyarafan

1. Kesemetrisan raut wajah:

......................................................................................................................

2. Tingkat kesadaran :
 Snile (Pikun) :
...................................................................................................................
 Daya ingat :
..................................................................................................................
3. Mata
- Pergerakan : ..................................................................
- Penglihatan : ..................................................................
- Penyakit penyerta : ..................................................................
4. Pupil
- Kesamaan : Isokor/AnIsokor

5. Ketajaman penglihatan : ..................................................................

 Jangan dites di depan jendela
 Pergunakan tangan atau gambar
 Cek kondisi kacamata
6. Sensori deprivation (gangguan sensorik) :
.......................................................
7. Ketajaman pendengaran :
......................................................
  Apakah menggunakan alat bantu dengar :
......................................................
 Tinitus :
......................................................
 Serumen :
.....................................................
8. Rasa sakit atau nyeri :
.....................................................

Sistem Kardivaskuler

1. Sirkulasi periper :
.....................................................
- Warna :
.....................................................
- Kehangatan :
.....................................................
2. Denyut nadi apikal :
....................................................
3. Pembengkakan vena jugularis :
....................................................
4. Pusing :
....................................................
5. Nyeri dada :
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6. Edema :
....................................................

Sistem Gastrointestinal

1. Status gizi :
.....................................................
2. Pemasukan diet :
....................................................
3. Anoreksia :
....................................................
4. Mual : ...................................................
5. Muntah : ...................................................
6. Mengunyah dan menelan : ...................................................
7. Keadaan gigi : ...................................................
8. Rahang : ..................................................
9. Rongga mulut : ..................................................
10. Bising usus : ...................................................
11. Keadaan perut : ..................................................
12. Konstipasi (sembelit) : ..................................................
13. Diare : .................................................
14. Inkontinesia alvi : .................................................

Sistem Genitourinarius

1. Warna dan bau urine : ................................................

2. Distensi kandung kemih : .................................................
3. Inkontinensia : ..................................................
4. Frekuensi : ..................................................
 5. Tekanan/ desakan :
.................................................
6. Pemasukan cairan :
...................................................
7. Pengeluaran cairan : ...................................................
8. Disuria :
.....................................................
9. Seksualitas
 Minat melaksanakan hubungan seks :
.....................................................
 Frekwensi :
.....................................................

Sistem Kulit

1. Kulit
 Temperatur
 Tingkat kelembaban
 Keadaan luka
- Luka terbuka/tertutup :
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- Robekan :
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 Turgor (kekenyalan kulit) :
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 Pigmen :
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2. Jaringan parut :
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3. Keadaan kuku :
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4. Keadaan rambut :
....................................................
5. Gangguan-gangguan umum :
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Sistem Muskuloskeletal
1. Kontraktur : ...................................................
 Otot : ..................................................
 Tendon : ..................................................
 Gerakan sendi : ..................................................

2. Tingkat mobilisasi
 Ambulasi (Dengan atau tanpa bantuan/peralatan) :
...................................................................
 Gerakan : .................................................
 Kekuatan otot : .................................................
 Kemampuan melangkah atau berjalan : ..................................................
3. Gerakan sendi : ...................................................
4. Paralisis : ..................................................
5. Kifosis : ...................................................

B. Psikologis
  Pengenalan masalah-masalah utama
 Sikap terhadap proses penuaan
 Perasaan dibutuhkan
 Pandangan terhadap kehidupan
 Koping Stressor
 Penyesuaian diri
 Kegagalan
 Harapan saat ini dan yang akan datang
 fungsi kognitif
- Daya ingat
- Proses pikir
- Alam perasaan
- Orientasi
- Kemampuan dalam penyelesaian masalah

C. Sosial Ekonomi

 Sumber keuangan
 Kesibukan dalam mengisi waktu luang
 Teman tinggal
 Kegiatan organisasi
 Pandangan terhadap lingkungannya
 Hubungan dengan orang lain di luar rumah
 Yang biasa mengunjungi
 Penyalurkan hobi/keinginan
sesuai fasilitas yang ada

D. Spiritual

 Kegiatan ibadah
 kegiatan keagamaan
 Cara Lanjut Usia menyelesaikan masalah
 Penampilan Lansia

E. Psikososial
 Tingkat ketergantungan
 Fokus diri
 Perhatian
 Rasa Kasih sayang
LAMPIRAN: 2

FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA TOMOHON

KLASIFIKASI DATA

NO DATA SUBYEKTIF DATA OBYEKTIF

FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA TOMOHON

PATOFLOW/PENYIMPANGAN KDM
LAMPIRAN : 3
FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA TOMOHON

ANALISA DATA

NO DATA ETIOLOGI MASALAH

LAMPIRAN : 4

FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA TOMOHON

FORMAT RENCANA ASUHAN KEPERAWATAN

Inisial klien : ……………………… Ruangan : ……………………………

No. RM : ……………………………

Rencana Tindakan Keperawatan

Diangnosa Intervensi
No Tujuan dan (Meliputi: tindakan keperawatan, tindakan
Keperawatan
Kriteria Hasil observasi,penyuluhan, pelaksanaan program
dokter)

1 2 3 4
LAMPIRAN : 5

FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA TOMOHON

FORMAT IMPLEMENTASI KEPERAWATAN

Inisial klien : ……………………… Ruangan : ……………………………

No. RM : ……………………………

DX.
No Implementasi Tindakan Keperawatan Nama Jelas
Kep Waktu
LAMPIRAN : 6

FAKULTAS KEPERAWATAN
UNIVERSITAS SARIPUTRA TOMOHON

FORMAT EVALUASI KEPERAWATAN

Nama / umur :
Ruang / kamar :
Hari/
Waktu Evaluasi (SOAP/SOAPIER) Nama Jelas
Tgl