CONTOH FORMAT ASUHAN KEPERAWATAN GERONTIK

PENGKAJIAN

Hari/tanggal pengkajian : ............................. Jam: .......................................................

A. Identitas Klien
1. Data Biografi Klien
Nama :..................................................
Jenis Kelamin :..................................................
Usia :..................................................
Agama :..................................................
Status Perkawinan :..................................................
Pendidikan Terakhir :..................................................
Pekerjaan :..................................................
Suku Bangsa :..................................................
Diagnosis Media :..................................................
Alamat Rumah :..................................................
2. Keluarga / orang terdekat yang dapat dihubungi
Nama :..................................................
Alamat :..................................................
No. Telpon :..................................................
Hubungan dengan klien :..................................................
3. Riwayat keluarga
4. Genogram (minimal 3 generasi) misalnya :
Keterangan :
: Laki-Laki
: Perempuan
: Meninggal
: Cerai
: Satu Rumah
: Klien
 5. Riwayat di Panti Wredha (jika klien di panti wredha)
Nama panti :.......................................
Alamat panti :.......................................
Tanggal masuk panti :.......................................
Alasan kunjungan ke pantai :
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Kunjungan keluarga :.....................................................................................................

B. Lingkungan Tempat Tinggal

1. Tipe tempat tinggal
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2. Penerangan
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3. Sirkulasi udarah
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4. Keadaan kamar mandi dan WC
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5. Pembuangan air kotor
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6. Sumber air minum
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7. Pembuangan sampah
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8. Sumber pencemaran
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9. Penataan halaman (jika ada)
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10. Privasi
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11. Risiko injuri
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C. Riwayat Kesehatan
1. Status Kesehatan Saat Ini
a. Keluhan utama dalam 1 tahun terakhir
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b. Gejala yang dirasakan
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c. Faktor pencetus
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d. Timbul keluhan : ( ) mendadak ( ) bertahan
 e. Waktu mulai timbulnya keluhan
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f. Upaya mengatasinya
( ) Pergi ke RS/klinik pengobatan/dokter praktik
( ) Pergi ke bidan/perawat
( ) Mengkonsumsi obat-obatan sendiri
( ) Mengkonsumsi obat-obatan tradisional
( ) lain-lain:
2. Riwayat Kesehatan Masa Lalu
a. Penyakit yang pernah diderita
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b. Riwayat kecelakaan
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c. Riwayat di rawat di rumah sakit
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d. Riwayat alergi
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e. Riwayat pemakaian obat

No Nama Dosis Keterangan

D. Kebiasaan sehari-hari
1. Biologis
 a. Pola makan
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b. Pola minum
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c. Pola istirahat dan tidur
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d. Pola eliminasi
BAK :
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BAB :
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e. Perawatan diri
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2. Rekreasi
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3. Psikologis
a. Pola persepsi diri
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 b. Manajemen koping stress
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4. Spiritual / kultural (pelaksanaan ibadah serta keyakinan tentang kesehatan
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E. Pemeriksaan Fisik
Keadaan umum :..................................
Tingkat kesadaran :.................................. GCS :....................................
TTV :..................................
BB/TB :..................................
Kepala :..................................
Leher :..................................
Dada :..................................
Abdomen :..................................
Genitalia :..................................
Kulit :..................................
Ekstremitas atas :..................................
Ekstremitas bawah :..................................
F. Pemeriksaan Penunjang
Pemeriksaan penunjang yang dikaji dengan hasil laboratorium, hasil pemeriksaan
rontgen, EKG, CT scan, terapi medis yang sedang dijalani, maupun informasi penunjang
lainnya.
G. Pemeriksaan khusus
1. Masalah Kesehatan Kronis
Menggunakan alat ukur masalah kesehatan kronis
2. Status Fungsional
Menggunakan alat ukur Indeks Barthel, Indeks Katz, atau dengan melakukan
pengkajian keseimbangan untuk lansia

3. Status Kognitif
 Menggunakan alat ukur Short Portable Mental Status Questionaire (SPMSQ), Mini
Mental State Exam (MMSE)
4. Status Afektif
Menggunakan alat ukur Inventaris Depresi Beck atau Skala Depresi Geriatrik
Yesavage. Dapat juga dilakukan pengkajian untuk mengidentifikasi masalah
emosional yang terdiri dari 2 tahap pertanyaan seperti yang telah dijelaskan pada
bagian alat ukur untuk melakukan pengkajian pada lansia sebelumnya.
5. Status Sosial
Menggunakan alat ukur APGAR keluarga yaitu adaptasi (Adaptasion), kemitraan
(Partnership), Pertumbuhan (Growth), afeksi (Afection) dan pemecahan (Resolve)

ANALISA DATA
No Data problem Etiologi
1. DS:
DO:
2. DS:
DO:
3. DS:
DO:

PERENCANAAN
No Dx Tujuan Kriteria Standar Rencana Intervensi
Verbal
(pengetahuan)
Psikomotor
(perilaku)

IMPLEMENTASI

Tanggal Diagnosis Implementasi Respon Paraf

S :
O:
S :
 O:

EVALUASI

No Tanggal Diagnosis Evaluasi Paraf

S :
O:
A:
P:
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O:
A:
P: