FORMAT PENGKAJIAN ASUHAN KEPERAWATAN GERONTIK

PENGKAJIAN PADA LANSIA

A. PENGKAJIAN
Hari/Tgl : ....................................................
Jam : ....................................................
Nama Mahasiswa : ....................................................

1. Identitas Klien
Nama : .....................................................................................................................
Tempat, Tgl lahir : .....................................................................................................................
Jenis kelamin : ...................................................................................................................
Status Perkawinan : ...................................................................................................................
Agama : .................................................................................................................
Suku : .................................................................................................................

2. Riwayat pekerjaan dan status Ekonomi

a. Pekerjaan saat ini : ........................................................................................................
b. Pekerjaan sebelumnya : .....................................................................................................
c. Sumber pendapatan : .........................................................................................................
d. Kecukupan pendapatan : ...............................................................................................

3. Lingkungan tempat tinggal

a. Kebersihan dan kerapihan ruangan : .................................................................................
b. Penerangan : ......................................................................................................
c. sirkulasi udara : ......................................................................................................
d. kedaan kamar mandi & WC : ...............................................................................................
e. Pembuangan air kotor : .............................................................................................
f. Sumber air minum : .............................................................................................
g. Pembuangan sampah : .......................................................................................
h. Sumber pencemaraan : .............................................................................................
i. Privasy : .............................................................................................
j. Resiko injury : .............................................................................................
4. Riwayat Kesehatan
a. Status kesehatan saat ini
1) Keluhan utama dalam 1 tahun terakhir : ....................................................................
2) Gejala yang di rasakan : ...........................................................................................
3) Faktor Pencetus : .............................................................................................
4) Timbul keluhan : ( ) Mendadak ( ) Bertahap
5) Upaya mengatasi : ............................................................................................
6) Pergi ke RS/klinik/pengobatan/dokter : .....................................................................
7) Mengkonsumsi obat-obatan sendiri, tradisonal: .............................................................
8) Lain-lain : ...............................................................................................................

b. Riwayat kesehatan masa lalu

1) Penyakit yang di derita : .............................................................................................
2) Riwayat alergi : .............................................................................................
a. Obat-obatan : ........................................................................................
b. Makanan : ........................................................................................
c. Binatang : .........................................................................................
d. Debu : .............................................................................................
3) Riwayat kecelakaan : ..........................................................................................
4) Riwayat pernah di rawat : ..........................................................................................
5) Riwayat pemakaian obat : .............................................................................................

5. Pola Fungsional
a. Persepsi Kesehatan dan pola manajemen kesehatan
Kebiasaan yang mempengaruhi kesehatan missal merokok, minum keras,
ketergantungan terhadap obat (jenis/frekuensi/jumlah/lama pakai).
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
............................................................................................................................................

b. Nutrisi Metabolik
Frekuensi makan : .........................................................................................................
Nafsu makan : .......................................................................................................
Jenis makanan : .....................................................................................................
Makanan yg tidak disukai : ...........................................................................................
Alergi thd makanan : .........................................................................................................
Pantangan makanan : .........................................................................................................
Keluhan byg berhubungan dgn makanan : .....................................................................
c. Eliminasi
BAK
Frekuensi & waktu : .........................................................................................................
Kebiassan BAK malam hari : ...............................................................................................
Keluhan yang berhubungan dgn BAK : ................................................................................

BAB
Frekuensi & waktu : .........................................................................................................
KOnsistensi : ........................................................................................................
Keluhan yg berhubungan dgn BAB : ...................................................................................
Pengalamam memakai pencahar : ........................................................................................

d. Aktifitas pola latihan

Rutinitas mandi : .........................................................................................................
Kebersihan sehari-hari : ......................................................................................................
Aktifitas sehari-hari : .........................................................................................................
Masalah aktifitas : ........................................................................................................

e. Pola istirahat tidur

Lama tidur malam : .........................................................................................................
Lama tidur siang : .........................................................................................................
Masalah tidur : .........................................................................................................

f. Pola kognitif persepsi

Masalah dengan penglihatan
( ) Normal ( ) Terganggu ( )kabur ( )pakai kacamata

Masalah dengan pendengaran

( )Normal ( ) Terganggu ( ) Memakai alat bantu dengar ( )tuli

g. Persepsi diri pola konsep diri

Bagaimana klien memandang dirinya : ................................................................................
Bagaimana klien tentang orang lain mengenai dirinnya : .................................................

h. Pola Peran hubungan

Peran ikatan : .....................................................................................................................
Kepuasaan : ................................................................................................................
Pekerjaan : ..............................................................................................................
Sosial : ................................................................................................................
Hub. perkawainan : ..............................................................................................................
 i. Seksualitas
Riwayat reproduksi : .........................................................................................................
Kepuasaan seksual : .........................................................................................................
Masalah seksual : .........................................................................................................

j. Koping pola Toleransi stress

Penyebab stress : .........................................................................................................
Penanganan stress : .........................................................................................................

k. Nilai pola keyakinan

Keyakinan agama : ........................................................................................................
Keyakinan akan kesehatan : .............................................................................................

6. Pemeriksaan fisik
Keadaan umum : .....................................................................................................................
TTV : .....................................................................................................................
BB/TB : .................................................................................................................
Kepala : .................................................................................................................
Rambut : ....................................................................................................................
Mata : .....................................................................................................................
Telinga : ....................................................................................................................
Mulut, gigi, bibir : ..................................................................................................................
Dada : .................................................................................................................
Abdomen : .....................................................................................................................
Kulit : .....................................................................................................................
Ekstermitas atas : .....................................................................................................................
Ektermitas bawah : .....................................................................................................................
B. ANALISA DATA

No. DATA ETIOLOGI MASALAH

1.
C. PRIORITAS MASALAH

Masalah Kriteria Bobot Skor Pembenaran

Keperawatan
Sifat Masalah

Kemungkinan di ubah

Potensial dicegah

Menonjolnya masalah

Total skor

D. DIAGNOSA KEPERAWATAN
(Berdasarkan prioritas Masalah)
E. INTERVENSI

Tgl
Diagnosa Tujuan Kriteria Intervensi Rasional
Keperawatan Hasil
Umum Khusus
F. IMPLEMENTASI

Tanggal No. DX Waktu Implementasi Evaluasi

Keperawatan Formatif
G. EVALUASI

Tanggal No. DX Evaluasi Sumatif Nama jelas &

Keperawatan Tanda Tangan