PENGKAJIAN KEPERAWATAN GERONTIK

Hari/Tgl. : ....................................... Kasus ke-1/ Inisial Klien: ........................................

A. Data Biografi
1. Nama : ............................................................................................
2. Jenis kelamin :L/P
3. Golongan darah : O / A / B / AB
4. Tempat & tanggal lahir : .......................................................................................
5. Pendidikan terakhir : SD/SLTP/SLTA/ DI/ DII/ DIII/ DIV/ S1/ S2/S3
6. Agama : Islam/Protestan/Katolik/Hindu/Budha/Konghucu/LL
7. Status perkawinan : Kawin / Belum / Janda / Duda (Cerai : hidup / mati)
8. Tinggi badan/berat badan : .......... cm .......... kg
9. Penampilan : ....................................... Ciri-ciri tubuh : .....................
10. Alamat : ………….......................................................................
11. Orang yang mudah dihubungi: .......................................................................................
12. Alamat & telepon : …………........................................................................

B. Riwayat Keluarga
Genogram :

Keterangan :

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C. Riwayat Pekerjaan
1. Pekerjaan saat ini : .......................................................................................
2. Alamat pekerjaan : ........................................... jarak dari rumah ......... km
3. Alat transportasi : .......................................................................................
4. Pekerjaan sebelumnya : .......................................... jarak dari rumah .......... km
5. Alat transportasi : ......................................................................................
6. Sumber-sumber pendapatan dan kecukupan terhadap kebutuhan : ...............................
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D. Riwayat Lingkungan Hidup
1. Type tempat tinggal : ..........................................................................................
2. Jumlah kamar : ............... Jumlah tingkat : ...............
3. Kondisi tempat tinggal : ..........................................................................................
4. Jumlah orang yang tinggal di rumah : Laki-laki = ........ orang / Perempuan = .........
orang
5. Derajat privasi : .........................................................................................
6. Tetangga terdekat : .........................................................................................
7. Alamat dan telepon : ..........................................................................................
E. Riwayat Rekreasi
1. Hobby/minat : ..............................................................................
2. Keanggotaan dalam organisasi :
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3. Liburan/perjalanan :
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F. Sistem Pendukung
1. Perawat/bidan/dokter/fisioterapi : ........................................ jaraknya ............. km
2. Rumah sakit : ......................................... jaraknya ............ km
3. Klinik : ......................................... jaraknya ............ km
4. Pelayanan kesehatan di rumah : ...........................................................................
5. Makanan yang dihantarkan : ...........................................................................
6. Perawatan sehari-hari yang dilakukan keluarga : ...........................................................
7. Lain-lain : ...........................................................................

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G. Deskripsi Kekhususan
1. Kebiasaan ritual : .....................................................................................................
2. Yang lainnya : .....................................................................................................
H. Status Kesehatan
1. Status kesehatan umum selama setahun yang lalu :
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2. Status kesehatan umum selama 5 tahun yang lalu :

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3. Keluhan utama :
a. Provokative/paliative : ...........................................................................................
b. Quality/quantity : ...........................................................................................
c. Region : ..........................................................................................
d. Severity Scale : ..........................................................................................
4. Pemahaman dan penatalaksanaan masalah kesehatan :
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5. Obat-obatan

No. Nama obat Dosis Ket

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 6. Status imunisasi (catat tanggal terbaru)
a. Tetaus, difteri : ...................................................................................................
b. Influensa : ..................................................................................................
c. Pneumovaks : ..................................................................................................
d. Lain-lain : ...................................................................................................
7. Alergi (catatan agen dan reaksi spesifik)
a. Obat-obatan : ..........................................................................................
b. Makanan : ..........................................................................................
c. Faktor lingkungan : ..........................................................................................
8. Penyakit yang diderita
( ) Hipertensi ( ) Rheumatoid ( ) Asthma ( ) Dimensia

Lain-lain : sebutkan ........................................................................................................

I. Aktivitas Hidup Sehari-hari (ADL)

1. Indeks Katz : A/B/C/D/E/F/G
2. Oksigenasi : ................................................................................................
3. Cairan & elektrolit : ................................................................................................
4. Nutrisi : ................................................................................................
5. Eliminasi : ................................................................................................
6. Aktivitas : ................................................................................................
7. Istirahat & tidur : ................................................................................................
8. Personal hygiene : ................................................................................................
9. Seksual : ................................................................................................
...
10. Rekreasi : ................................................................................................
11. Psikologis
a. Persepsi klien : ..............................................................................
b. Konsep diri : ..............................................................................
c. Emosi : ..............................................................................
d. Adaptasi : ..............................................................................
e. Mekanisme pertahanan diri : ..............................................................................
J. Tinjauan Sistem
 Keadaan umum : ................................................................................................
 Tingkat kesadaran : Compos mentis / Apatis / Somnolen / Stuport / Coma

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 Skala Koma Glasgow : Verbal = ...... Psikomotor = .......... Mata = .......... Total =
 Tanda-tanda vital : Pulse = ....... Temp = ......... RR = ....... Tensi = ........ mmHg

1. Kepala
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2. Mata, telinga, hidung

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3. Leher
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4. Dada & punggung

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5. Abdomen & pinggang

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6. Ekstremitas atas dan bawah

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7. Sistem immune
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 8. Genetalia
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9. Sistem reproduksi
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10. Sistem persyarafan

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11. Sistem pengecapan

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12. Sistem penciuman

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13. Tactil respon

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K. Status Kognitif / Afektif / Sosial

1. Short Portable Mental Status Questionnaire (SPMSQ)
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2. Mini-Mental State Exam (MMSE)

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 3. Inventaris Depresi Beck
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4. APGAR keluarga
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L. Data Penunjang
1. Laboratorium
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2. Radiologi :
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3. ECG :
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4. USG :
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5. CT-Scan :
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6. Obat-obatan:
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.............., ................. 2016

Mahasiswa

(............................................)

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 ANALISA DATA

Hari/Tgl. : .......................................... Kasus ke-1/Inisial Klien : .............................

DATA FOKUS DIAGNOSA KEPERAWATAN

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