FORMAT PENGKAJIAN KEPERAWATAN GERONTIK

UNIVERSITAS AUFA ROYHAN

Di KOTA PADANGSIDIMPUAN
SK Mendiknas RI No. 270/E/O/2011, 1 Desember 2011
SK Mendikbud RI No. 322/E/O/2013, 22 Agustus 2013
Jl. Raja Inal Siregar Kel. Batunadua Julu, Kota Padangsidimpuan 22733. Telp.(0634) 7366507 Fax. (0634) 22684
e -mail: aufa.royhan@yahoo.com http//: stikes.aufa.ac.id

FORMAT PENGKAJIAN INDIVIDU

Tanggal Pengkajian:

A. Identitas Klien
 Nama :
 Tempat/Tgl Lahir :
 Jenis Kelamin :
 Satus Perkawina :
 Agama :
 Suku :
 Pendidikan Terakhir :
 Gol. Darah :
 TB/BB :
 Alamat :

B. Identitas Penanggung Jawab

 Nama :
 Hubungan dengan Klien :

C. Riwayat Keluarga
 Genogram (buat 3 Generasi)

 Alasan Masuk Panti

Wreda .............................................................................................................................
.........................................................................................................................................
.........
 Keluhan
Utama .............................................................................................................................
.........................................................................................................................................
.........
  Pemahaman dan penatalaksanaan masalah
kesehatan ........................................................................................................................
.........................................................................................................................................
...............
 Obat-obatan

No Nama Obat Dosis keterangan

1
2
3

 Status Imunisasi
.........................................................................................................................................
.......................................................................................................................................
 Alergi
.........................................................................................................................................
.......................................................................................................................................
 Penyakit Yang diderita
Hipertensi
Demensia
Rematik
Asma
Jantung
Katarak
Lain-lain, sebutkan bila ada............................................................................................

D. Riwayat Pekerjaan
 Pekerjaan saat ini : ..........................................................................................
 Alamat pekerjaan : ...........................................................................................
 Jarak dari rumah : ...........................................................................................
 Alat transportasi : ...........................................................................................
 Sumber pendapatan : ..........................................................................................

E. Riwayat Lingkungan Hidup

 Tipe tempat tingga : ...........................................................................................
 Jumlah kamar : ...........................................................................................
 Jumlah tongkat : ...........................................................................................
 Kondisi tempat tinggal : ...........................................................................................

F. Riwayat Rekreasi
 Hobi/minat : ...........................................................................................
 Keanggotaan organisasi : ...........................................................................................

G. Pengkajian Aktivitas Hidup Sehari-hari (ADL)

 Oksigenasi
 .........................................................................................................................................
........................................................................................................................................
 Cairan dan elektrolit
.........................................................................................................................................
........................................................................................................................................
 Nutrisi
.........................................................................................................................................
.......................................................................................................................................
 Eliminasi
.........................................................................................................................................
........................................................................................................................................
 Aktivitas
.........................................................................................................................................
........................................................................................................................................
 Istirahat dan tidur
.........................................................................................................................................
........................................................................................................................................
 Personal Hygiene
.........................................................................................................................................
........................................................................................................................................
 Seksual
.........................................................................................................................................
........................................................................................................................................
 Rekreasi
.........................................................................................................................................
........................................................................................................................................

H. Psikologis
 Persepsi klien
.........................................................................................................................................
........................................................................................................................................
 Konsep diri
.........................................................................................................................................
........................................................................................................................................
 Emosi
.........................................................................................................................................
........................................................................................................................................
 Adaptasi
.........................................................................................................................................
........................................................................................................................................
 Mekanisme pertahanan diri
.........................................................................................................................................
........................................................................................................................................

I. Pemeriksaan Fisik
 Keadaan umum
 Tingkat Kesadaran : CM/Apatis/Somnolen/Sopor/Koma
 GCS : Verbal : ...... Psikomotor : ........ Mata : ..........

 Tanda-tanda vital
a. Temperature : C
b. Pulse : x/m
c. Respiratory Rate : x/m
d. Blood Pressure : mmHg

 Kepala
.........................................................................................................................................
........................................................................................................................................
 Mata, hidung, dan telinga
.........................................................................................................................................
........................................................................................................................................
 Leher
.........................................................................................................................................
........................................................................................................................................
 Dada dan punggung
.........................................................................................................................................
........................................................................................................................................
 Abdomen dan pinggang
.........................................................................................................................................
........................................................................................................................................
 Ekstremitas atas dan bawah
.........................................................................................................................................
........................................................................................................................................
 Sistem imun
.........................................................................................................................................
........................................................................................................................................
 Genitalia
.........................................................................................................................................
........................................................................................................................................
 Sistem reproduksi
.........................................................................................................................................
........................................................................................................................................
 Sistem persarafan
.........................................................................................................................................
........................................................................................................................................
 Sistem pengecapan
.........................................................................................................................................
........................................................................................................................................
 Sistem penciuman
 .........................................................................................................................................
........................................................................................................................................
 Respon taktil
.........................................................................................................................................
........................................................................................................................................

J. Pengkajian Fungsional Fungsional/Kognitif/Afektif dan Sosial

a. Pengkajian Status Kognitif dan Afektif/Short Portable Status Questionnaire
(SPMSQ)

Short Portable Mental Status Quistionarre (SPSMQ)

Skor No Pertanyaan Jawaban
+ -
1 Tanggal berapa hari ini?
2 Hari apa sekarang?
3 Apa nama tempat ini?
4 Berapa nomor telepon anda?
5 Diaman alamat anda?
6 Kapan anda lahir?
7 Siapa presiden RI sekarang?
8 Siapa presiden sebelumnya?
9 Siapa nama kecil ibu anda?
10 Kurangi 3 dari 20
Jumlah kesalahan total
Penilaian SPMSQ
1. Kesalahan 0-2 : fungsi intelektual utuh
2. Kesalahan 3-4 : fungsi intelektual ringan
3. Kesalahan 5-7 : fungsi intelektual sedang
4. Kesalahan 8-10 : fungsi intelektual berat

b. Pengkajian Status Sosial (APGAR Keluarga)

APGAR KELUARGA
NO FUNGSI URAIAN Selalu Kadang2 Tidak
(2) (1) pernah
(0)
1 A: Adaptasi Saya puas dapat kembali kepada keluarga
saya untuk membantu pada saat saya
mengalami kesusahan
2 P: Saya puas dengan cara keluarga saya
Partnershipt membicarakan sesuatu dengan saya dan
Hubungan mengungkapkan masalah dengan saya
3 G : Growth Saya puas bahwa keluarga saya
Pertumbuhan menerima dan mendukung keinginan
saya untuk melakukan aktivitas atau
kegiatan baru
4 A; Afek Saya puas dengan cara keluarga saya
Afeksi /kasih mengekspresikan afek dan berespon
sayang terhadap emosi-emosi saya, seperti
marah, sedih, atau mencintai
5 R: Resolve Saya puas dengan cara teman saya dan
 Pemecahan saya menyediakan waktu bersama-sama
Penilaian
Nilai : 0-3 Disfungsi keluarga sangat tinggi / tidak baik
Nilai : 4-6 Disfungsi keluarga sedang / kurang baik
Nilai : 7-10 Disfungsi keluarga rendah / baik

K. Data Penunjang
1. Laboratorium
..........................................................................................................................................
.......................................................................................................................................
2. Radiologi
..........................................................................................................................................
.......................................................................................................................................
3. EKG
..........................................................................................................................................
.......................................................................................................................................
4. USG
..........................................................................................................................................
.......................................................................................................................................
5. CT Scan
..........................................................................................................................................
.......................................................................................................................................
6. Obat-obatan
..........................................................................................................................................
.......................................................................................................................................

L. Analisa Data

No Data / Tanda dan gejala Etiologi Masalah

M. Prioritas Masalah

N. Diagnosa Keperawatan
 O. ASUHAN KEPERAWATAN LANSIA

N Diagnosis Tujuan / Kriteria Intervensi Rasional Evaluasi

O Hasil
1