PENGKAJIAN KEPERAWATAN LANSIA

A. DATA BIOGRAFI
Nama :
Jenis kelamin :
Umur :
Pendidikan terakhir :
Agama :
Status perkawinan :
Tinggi badan/berat badan :
Penampilan umum :
Ciri-ciri tubuh :
Alamat :
Orang yang mudah dihubungi :
Hubungan dengan klien :

B. Riwayat Keluarga
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Genogram :

Keterangan :

C. Riwayat Pekerjaan
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D. Riwayat Lingkungan Hidup
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E. Riwayat Rekreasi
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F. Sistem Pendukung
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G. Diskripsi kekhususan
Kebiasaan ritual :
Yang lainnya :

H. Status Kesehatan
Status kesehatan umum selama lima tahun yang lalu :
………………………………………………………………
 …………………………………………………………………………………………………
……………………………
Keluhan utama : ……………………………………………
Obat-obatan
NO NAMA OBAT DOSIS KET
1
2
3

Status imunisasi :
Alergi :
Obat-obatan :
Makanan :
Faktor lingkungan :
Penyakit yang diderita :

I. Aktivitas Hidup Sehari-hari

Nutrisi :
Eliminasi :
Aktivitas :
Istirahat dan tidur :
Personal hygiene :
Seksual :
Rekreasi :
Psikologis :
· Persepsi klien :
· Konsep diri :
· Emosi :
· Adaptasi :
· Mekanisme pertahanan diri :

J. Tinjauan Sistem Organ

Keadaan umum :…………………………………………….
Tingkat kesadaran : ……………………………………………
GCS : ……………………………………………
Tanda-tanda vital : TD : …..........mmHg RR : ….......x/menit
S : ….............◦C Nadi : ……...x/menit
Sistem Integumen
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Hemopoetik
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Kepala
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Mata
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Telinga
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Hidung dan sinus
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Mulut dan tenggorokan
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Leher
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Payudara
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Sistem Pernapasan
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Sistem kardiovaskuler
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Sistem perkemihan
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Sistem musculoskeletal
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Sistem endokrin
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Sistem imunitas
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Sistem gastrointestinal
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Sistem reproduksi
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Sistem persyarafan
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Sistem pengecapan
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Sistem penciuman
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K. Data Tambahan
Short Porteble Mental Status Questionaire ( SPMSQ )
= ………………………..
Mini - Mental State Exam ( MMSE )
= ………………………..
Depresi Geriatri
= ………………………..
APGAR Keluarga
= ………………………..
L. Data Penunjang
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Kediri, ……………..

(………………………)
 ANALISA DATA
Nama Klien :………………
Dx Medis : ……………..

NO DATA ETIOLOGI MASALAH PARAF

INTERVENSI KEPERAWATAN
Nama Klien :………………
Dx Medis : ……………..

TUJUAN &
NO DX KEP INTERVENSI RASIONAL
KRITERIA HASIL
 IMPLEMENTASI KEPERAWATAN
Nama Klien :………………
Dx Medis : ……………..

NO TGL JAM IMPLEMENTASI EVALUASI PARAF

DX (SOAP)
S:

O:

A:

P:

CATATAN PERKEMBANGAN
Nama Klien :………………
Dx Medis : ……………..

NO
TGL S 0 A P I E PARAF
DX