UNIVERSITAS MUHAMMADIYAH PONOROGO FAKULTAS ILMU

KESEHATAN
Jl. Budi Utomo No 10 Telp. (0352)487662 P onorogo

FORMAT ASUHAN KEPERAWATAN PADA LANJUT

USIA

Nama Mahasiswa : Eplin Febriana Putri

NIM : 18613220

A. PENGKAJIAN
I. IDENTITAS 1. Lansia
Nama : ____________________________________________
Alamat : ____________________________________________
Jenis Kelamin : ____________________________________________
Umur : ____________________________________________
Status : ____________________________________________
Agama : Islam
Suku : Jawa
Riwayat Pendidikan : SD
____________________________________________
Riwayat Pekerjaan : ____________________________________________
Sumber Pendapatan : ____________________________________________
Tempat tinggal sekarang : ____________________________________________
Lama Tinggal 2. : ____________________________________________

P enanggung
jawab
Nama : ____________________________________________
Alamat : ____________________________________________
Hubungan dengan lansia : ____________________________________________
No Telepon : ____________________________________________

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II. RIWAYAT KESEHATAN A. Status Kesehatan Saat Ini
1. Keluhan yang dirasakan saat ini :
_____________________________________
___________________________________________________________________________
_____________________________________________________
2. Faktor Pencetus : __________________________________________________
___________________________________________________________________________
_____________________________________________________
3. Waktu timbulnya keluhan : __________________________________________
___________________________________________________________________________
_____________________________________________________
4. Kondisi yang memperingan dan memperberat keluhan : __________________
___________________________________________________________________________
_____________________________________________________
5. Upaya yang telah dilakukan : ________________________________________
___________________________________________________________________________
_____________________________________________________

B. Masalah Kesehatan Kronis (format terlampir)

___________________________________________________________________

C. Riwayat Kesehatan Masa Lalu

1. Penyakit yang pernah diderita : _______________________________________
___________________________________________________________________________
_______________________________________________________
2. Riwayat jatuh/kecelakaan : __________________________________________
___________________________________________________________________________
_______________________________________________________
3. Riwayat dirawat di rumah sakit : ______________________________________
_________________________________________________________________
_________________________________________________________________
4. Riwayat pemakaian obat : ___________________________________________
_________________________________________________________________

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 _________________________________________________________________
5. Riwayat alergi (obat, makanan, debu, dan lain-lain) : ______________________
___________________________________________________________________________
_______________________________________________________

D. Riwayat Kesehatan Keluarga

1. Penyakit yang pernah diderita keluarga : ________________________________
_________________________________________________________________
_________________________________________________________________
2. Genogram :

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III. STATUS FISIOLOGIS A. P ola Kebiasaan Sehari-Hari

1. Nutrisi
a. Frekuensi makan : _______________________________________________
b. Jenis makanan : _________________________________________________
______________________________________________________________
______________________________________________________________
c. Kebiasaan makan : ______________________________________________
______________________________________________________________
______________________________________________________________
d. Makanan yang disukai : __________________________________________
______________________________________________________________
______________________________________________________________
e. Makanan tidak disukai : __________________________________________
______________________________________________________________
______________________________________________________________
f. Pantangan makan : ______________________________________________
______________________________________________________________
______________________________________________________________
g. Keluhan makan : ________________________________________________
______________________________________________________________
______________________________________________________________

2. Eliminasi
a. Frekuensi
- BAK : _____________________________________________________
- BAB : _____________________________________________________ b. Konsistensi
- BAK : _____________________________________________________
- BAB : _____________________________________________________
c. Kebiasaan
- BAK : _____________________________________________________
- BAB : _____________________________________________________ d. Keluhan
- BAK : _____________________________________________________

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- BAB : _____________________________________________________
e. Riwayat pemakaian obat (diuretic, laxative/pencahar dll)
______________________________________________________________
______________________________________________________________
______________________________________________________________

3. Istirahat/Tidur :
a. Frekuensi tidur : _________________________________________________ b. Lama Tidur
:____________________________________________________
c. Kebiasaan Tidur : _______________________________________________
_______________________________________________________________
_______________________________________________________________
d. Keluhan Tidur
:__________________________________________________
___________________________________________________________________________
___________________________________________________
e. Riwayat penggunaan obat tidur :
_____________________________________
___________________________________________________________________________
___________________________________________________

4. Aktifitas Sehari-hari :
a. Kegiatan yang dilakukan sehari-hari : _________________________________
___________________________________________________________________________
___________________________________________________
b. Kegiatan olahraga :
_______________________________________________
___________________________________________________________________________
___________________________________________________

c. Kebiasaan mengisi waktu luang : ____________________________________

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 ___________________________________________________________________________
___________________________________________________
d. Kemandirian dalam beraktifitas (format terlampir)
___________________________________________________________________________
___________________________________________________
e. Keseimbangan (format terlampir)
___________________________________________________________________________
___________________________________________________

5. Personal Higiene
a. Kebiasaan mandi :
________________________________________________
___________________________________________________________________________
___________________________________________________
b. Kebiasaan gosok gigi :
_____________________________________________
___________________________________________________________________________
___________________________________________________
c. Kebiasaan cuci rambut : ___________________________________________
___________________________________________________________________________
___________________________________________________
d. Kebiasaan gunting kuku : __________________________________________
___________________________________________________________________________
___________________________________________________

6. Reproduksi dan Seksual

___________________________________________________________________________
_________________________________________________________________
_______________________________________________________

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B. P emeriksaan Fisik

1. Tanda-Tanda Vital dan Status Gizi

- Suhu : ____________________________________________
- Tekanan Darah : ___________
_________________________________
- Nadi : ___________
_________________________________
- Respirasi : ____________________________________________
- Berat badan : ____________________________________________
- Tinggi badan : ____________________________________________

- IMT : ___________________________________________
2. Kepala : _____________________________________________________________
___________________________________________________________________________
_____________________________________________________________
3. Mata : _______________________________________________________________
___________________________________________________________________________
_______________________________________________________________
4. Hidung :
______________________________________________________________
___________________________________________________________________________
_______________________________________________________________
5. Mulut, Gigi dan Tenggorokan :
____________________________________________
___________________________________________________________________________
_______________________________________________________________
6. Telinga : _____________________________________________________________
___________________________________________________________________________
_______________________________________________________________
7. Leher : _______________________________________________________________
___________________________________________________________________________
_______________________________________________________________
8. Dada :

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 _______________________________________________________________
___________________________________________________________________________
_______________________________________________________________

9. Payudara : ___________________________________________________________
___________________________________________________________________________
_____________________________________________________________
10. Abdomen : ___________________________________________________________
___________________________________________________________________________
_____________________________________________________________
11. Genetalia : ___________________________________________________________
___________________________________________________________________________
_____________________________________________________________
12. Ekstremitas : _________________________________________________________
___________________________________________________________________________
_____________________________________________________________
13. Integumen : __________________________________________________________
____________________________________________________________________
____________________________________________________________________

IV. STATUS KOGNITIF

A. Fungsi Kognitif (format terlampir) :
________________________________________
_____________________________________________________________________

V. STATUS PSIKOSOSIAL DAN S P IRITUAL A. P sikologis

1. Persepsi Lansia terhadap proses menua

___________________________________________________________________________
_____________________________________________________________________
_______________________________________________________________

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 2. Harapan Lansia terhadap proses menua
___________________________________________________________________________
_____________________________________________________________________
_______________________________________________________________
3. Status Depresi (format terlampir) : _____________________________________

B. Sosial
1. Dukungan Keluarga (format APGAR LANSIA terlampir) :
_________________________________________________________________
2. Pola Komunikasi dan Interaksi lansia
:___________________________________
___________________________________________________________________________
_______________________________________________________

C. Spiritual
1. Kegiatan Keagamaan : _______________________________________________
___________________________________________________________________________
_________________________________________________________
2. Konsep keyakinan tentang kematian : ___________________________________
___________________________________________________________________________
_________________________________________________________
3. Upaya untuk meningkatkan spiritualitas : ________________________________
___________________________________________________________________________
_________________________________________________________

VI PENGKAJIAN LINGKUNGAN TEM P AT TINGGAL

A. Kebersihan dan Kerapihan ruangan :

_______________________________________
___________________________________________________________________________
_______________________________________________________________

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 B. Penerangan : _________________________________________________________
___________________________________________________________________________
_______________________________________________________________
C. Sirkulasi Udara : _______________________________________________________
___________________________________________________________________________
_______________________________________________________________
D. Keadaan kamar mandi dan WC :
__________________________________________
___________________________________________________________________________
_______________________________________________________________

E. Pembuangan air kotor : _________________________________________________

___________________________________________________________________________
_______________________________________________________________
F. Sumber air minum : ____________________________________________________
___________________________________________________________________________
_______________________________________________________________
G. Pembuangan sampah : __________________________________________________
___________________________________________________________________________
_______________________________________________________________
H. Sumber Pencemaran : __________________________________________________
___________________________________________________________________________
_______________________________________________________________

VII. INFORMASI TAMBAHAN

___________________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

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 _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
___________________________________________________________________

______________,__________________

(______________________)

B. ANALISA DATA
NO DATA PROBLEM ETIOLOGI

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______________,__________________

(______________________)

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C. DAFTAR DIAGNOSIS
NO TANGGAL DIAGNOSIS KEPERAWATAN

______________,__________________

(_______________________________)

D. RENCANA KEPERAWATAN

N DIAGNOSIS LUARAN (SLKI) KRITERIA INTERVENSI (SIKI)

O KEPERAWATAN HASIL

(SDKI)

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 Gangguan pola tidur Setelah dilakukan Intervensi utama :.....
b.d penerangan lampu tindakan 2x dalam 24 Intervensi pendukung:.......
terlalu kuat jam, diharapkan.....
Definisi: ............. gangguan pola tidur
Faktor penyebab: ...........
................... Luaran Utama:.....
Gejala mayor: ...... Luaran tambahan:......
Dengan kriteria hasil
(sesuai dengan luaran):
--------------------

______________,__________________

(_______________________________)
E. TINDAKAN KEPERAWATAN

NO TANGGAL/JA IMPLEMENTASI DAN RESPON TTD

M

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 1. O-T-E-K v
R/ XXX  RESPON: ...........

F. EVALUASI

NO TANGGAL/JA CATATAN PERKEMBANGAN TTD

M

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S:...............  keluhan pasien ??
O: ................................  sesuaikan luaran ???
A: masalah keperawatan  gangguan pola tidur
menurun  sesuai luaran ?
P: 1.  yang masih harus diimplementasikan pada
pasien.

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