FORMAT PENGKAJIAN GERONTIK

A. DATA UMUM
Nama : ………………………………………………………………
Umur : ………………………………………………………………
Jenis Kelamin : ………………………………………………………………
Agama : ………………………………………………………………
Suku : ………………………………………………………………
Keluarga yang dapar dihubungi : ………………………………………………
Telpon : ………………………………………………………………
Tanggal masuk panti : ………………………………………………………

1. Riwayat Kesehatan
Diagnosa medis (bila ada) : ………………………………………………….
a. Keluhan utama :
………………………………………………………………………………………
………………………………………………………………………………………
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b. Riwayat jatuh/injuri : (penyebab, gejala, tempat jatuh)
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
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c. Riwayat penyakit dahulu :
………………………………………………………………………………………
………………………………………………………………………………………
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 d. Riwayat penggunaan obat-obatab :
………………………………………………………………………………………
………………………………………………………………………………………
…………………………………………………………………………….................
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2. Riwayat Keluarga
a. Genogram

b. Orang terdekat dengan klien :

……………………………………………………………………………

3. Riwayat Pekerjaan
a. Pekerjaan saat ini : ………………………………………………………
b. Alamat pekerjaan : ………………………………………………………
c. Jarak dari rumah : ………………………………………………………
d. Alat transportasi : ………………………………………………………
e. Pekerjaan sebelumnya : ………………………………………………

B. PENGKAJIAN FISIK
1. Data Klinik :
 Tinggi Badan ….. cm Berat Bada ….. Kg
 Temperature ….. oC Nadi ….. x/menit (kuat/lemah/teratur/tidak)
 Tekanan Darah ….. mmHg
2. Pernafasan dan Sirkulasi :
 Frekuensi Nafas : ………………………………………………………...
 Kualitas : normal dangkal cepat
 Batuk : ya tidak, jelaskan : ……………………………………......
 Auskultasi :
 Lobus kanan atas : normal, menurun, tidak ada,
Suara tidak normal
 Lobus kiri atas : normal, menurun, tidak ada
Suara tidak normal
 Lobus kanan bawah : normal, menurun, tidak ada
Suara tidak normal
 Lobus kiri bawah : normal, menurun, tidak ada
Suara tidak normal

3. Metabolic Integumen :
 kulit :
 warna : normal, pucat, cyanosis, kuning,
lainnya ! ....................................................................................................
 Turgor : normal, menurun
 Lecet : tidak, ya. Sebutkan ! ………………………………………
 Bengkak : tidak, ya. Sebutkan ! ………………………………….
 Bercak : tidak, ya. Sebutkan ! ……………………………………
 Mulut :
 Gusi : normal, putih, lecet, lainnya, ……………………...
 Gigi : normal, lainnya, sebutkan ! …………………………………
 Abdomen : ………x/menit, peristaltic usus : ada, tidak ada

4. Pernafasan Sensori :
 Pupil : sama, tidak sama, sebutkan ! ……………………………….
 Reaksi terhadap cahay :
 Kiri : ya, tidak,
 Kanan : ya, tidak
 Mata : jelas, berair, kabur, lainnya, sebutkan ! ………….
 5. Musculoskeletal :
 Range of Motion : penuh, tidak, sebutkan ! ……………………….
 Keseimbangan : stabil, tidak stabil, sebutkan ! ……………………
 Menggenggam :
 Kanan : kuat, lemah
 Kiri : kiri, lemah
 Kekuatan oto kaki :
 Kanan : kuat, lemah
 Kiri : kuat, lemah

C. POLA KEBIASAAN SEHARI-HARI

1. Nutrisi :
a. frekuensi makan : …………………………………………………...............
b. jenis makan : ………………………………………………………………..
c. nafsu makan : ……………………………………………………………….
2. Eliminasi :
A. Berkemih
a. Frekuensi : …………………………………………………………….....
b. Warna : ………………………………………………………………......
c. Keluhan yang berhubungan dengan BAK : ……………………………..
B. Defekasi
a. Frekuensi : ………………………………………………………………
b. Warna, konsistensi : ……………………………………………………..
c. Keluhan yang berhubungan dengan defekasi : ………………………….

3. Hygiene Personal
a. Mandi (frekuensi) : …………………………………………………………
b. Sikat gigi : …………………………………………………………………..
c. Cuci rambut : ……………………………………………………………….
d. Gunting kuku : ……………………………………………………………...
e. Ganti pakaian : ……………………………………………………………..

4. Istirahat dan Tidur

 a. Lama tidur : ……………………………………………………………….
b. Tidur siang (ya/tidak) : ……………………………………………………

5. Aktivitas dan Latihan :

a. Olahraga (ya/tidak) : ……………………………………………………..
b. Kegiatan waktu luang : …………………………………………………..
c. Keluhan dalam beraktivitas : …………………………………………….

D. AKTIFITAS DAN LATIHAN

Kemampuan perawatan diri :
Skor : 0 = mandiri, 1 = dibantu sebagian, 2 = perlu bantuan orang lain, 3 = perlu bantuan
orang lain dan alat, 4 = tergantung/tidak mampu.
Aktifitas 0 1 2 3 4
Mandi
Berpakaian
Mobilisasi di tempat tidur
Pindah
Ambulasi
Naik tangga
Belanja
Memasak
Merapikam rumah
Indeks kemandirian Katz : ……………………………………………………
E. KOGNITIF DAN PERSEPTUAL
 Status mental :
 Tingkat kesadaran : ………………………………………………………
 Afasia : ……………………………………………………………………
 Dimensia : ya, tidak
 Orientasi : n normal, bingung, tidak ada respon
 Bicara : normal, gagap, afasia, bloking
 Bahasa yang digunakan : ……………………………………………………
 Kemampuan membaca : bisa, tidak
 Kemampuan interaksi : sesuai, tidak. Sebutkan ! ………………..
 Pendengara : normal, tergangguan kanan/kiri, tuli kanan/kiri
Alat bantu pendengaran, tinnitus.
  Penglihatan : normal, kacamat, lensa kontak, terganggu kanan/kiri,
buta kanan/kiri, kabur kanan/kiri, lainnya.
Sebutkan!.............................................................................................................
 Vertigo : ya, tidak.

F. LINGKUNGAN
 Jenis lantai rumah : tanah, tegel, poselin, lainnya.
Sebutkan ! ……………………………………………………………………...
 Kondisi lantai : licin, lembab, kering, lainnya.
Sebutkan ! ……………………………………………………………………..
 tangga rumah : tidak ada, ada
t : aman, tidak aman
 Penerangan : cukup, terang
 Tempat tidur : aman (pagar pembatas, tidak terlalu tinggi) tidak aman
 Alat dapur : berserakan, tertata rapi
 WC : tidak ada, ada aman, (posisi duduk, ada pegangan)
Tidak aman, (lantai licin, tidak ada pegangan)
 Kebersihan lingkungan : bersih (tidak ada barang membahayakan),
Tidak bersih dan tidak aman (pecahan kaca, gelas, paku dll)
G. PENGETAHUAN
Pengetahuan klien tentang kesehatan dirinya :
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NAMA : ..................................................
DX MEDIS : ..................................................
Data Penunjang
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ANALISA DATA
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DIAGNOSA KEPERAWATAN
Masalah
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NAMA : .................................................. NO.RM : ...............
DX MEDIS : ..................................................

N Tgl Diagnosa Keperawatan Tgl. Teratasi

o Muncul
 RENCANA TINDAKAN KEPERAWATAN

NAMA : .................................................. NO.RM : ...............

DX MEDIS : ..................................................

No. Diagnosa Keperawatan NOC NIC

No. Diagnosa Keperawatan NOC NIC
No. Diagnosa Keperawatan NOC NIC
 IMPLEMENTASI KEPERAWATAN

NAMA : .................................................. NO.RM : ...............

DX MEDIS : ..................................................

Tgl/jam No. DX Implementasi Keperawatan TTD Evaluasi

Tgl/jam No. DX Implementasi Keperawatan TTD Evaluasi

Tgl/jam No. DX Implementasi Keperawatan TTD Evaluasi
Tgl/jam No. DX Implementasi Keperawatan TTD Evaluasi