FORMAT PENGKAJIAN KLIEN LANSIA

(Kasus Kelolaan)

Tanggal Pengkajian : ............................

Nama Pengkaji : ............................

I. PENGKAJIAN
A. Data biografi
Nama : Tn. C L / P
Tempat & Tanggal lahir : Mataram, 09-february-1963 Gol. Darah : O
Pendidikan terakhir : SMA
Agama : Islam
Status Perkawinan : Kawin
TB/BB : 165 Cm/ 55 Kg
Penampilan : .................... Ciri-ciri tubuh : ......................................
Alamat : Dusun Dopang Selatan Desa Dopang
Telp.
Orang yang dekat dihubungi : Ny. S
Hubungan dengan usila : Istr
Alamat : Dusun Dopang Selatan Desa Dopang
Tanggal masuk panti :-
B. Riwayat keluarga
- Genogram.

- Keterangan.
C. Riwayat Pekerjaan :
Pekerjaan saat ini : Wiraswasta
Alamat pekerjan : Dirumah Dusun Dopang Selatan Desa Dopang
Berapa jarak dari rumah : 0 Km
Alat transportasi : -
Pekerjaan sebelumnya : wiraswasta
Berapa jarak dari rumah : 0 Km
Alat Transportasi : -
Sumber –sumber pendapatan & kecukupan terhadap kebutuhan : pasien mengatakan
sejak dulu bekerja membuka jasa service alat electronik dan membuka jasa cas aki motor
dan mobil

D. Riwayat Lingkungan Hidup

Tipe tempat tinggal : .........................................................................................
Jumlah kamar : 3 kamar tidur Jumlah tongkat ............................
Kondisi tempat tinggal
: ........................................................................................... ..........................................
.............................................................................................................(pencahayaan cukup
terang, ventilasi baik tidak lembab, bersih tidak pengap)
Jumlah orang yang tinggal dirumah : Laki-laki = 1 orang / Perempuan = 1 orang
Derajat privasi : .............................................................................................................
Tetangga
terdekat : ............... ...................................................... ............................ ........................
................................................................................................................................................
...........(sarana penghuni panti di wisma sendiri dan wisma lainnya)
Alamat / telpon : ................................................................................................ .......

E. Riwayat rekreasi
Hobby/minat : ........................................................................................................
Keanggotaan organisasi : ..............................................................................................-
Liburan perjalanan : ......................................................................................... ...........
F. Sistem pendukung
Perawat/Bidan/Dokter/Fisioterapi : .....................................................................
Jarak dari rumah : .............................................................................................
Rumah Sakit : ................................................................Jaraknya ...................Km
Klinik : .............................................................. Jaraknya .................. Km
Pelayanan Kesehatan di rumah : ..........................................................................
Makanan yang dihantarkan : .........................................................................................
Perawatan sehari-hari yang dilakukan keluarga : .................................................
. ......................................................................................................................................
Lain-lain : ...........................................................................................................
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G. Diskripsi Kekhususan
Kebiasaan ritual : ......................................................................................................
Yang lainnya : .....................................................................................................
H. Status Kesehatan
Status kesehatan untuk selama setahun yang lalu : .............................................
.........................................................................................................................................
Status kesehatan umum selama 5 tahun yang lalu : ..............................................
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I. Riwayat Kekerasan Fisik/Seksual : .................................................................................
..........................................................................................................................................

J. KELUHAN UTAMA : …………………………………………………………….

…………………………………………………………….
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● Provokative / Paliative : .............................................................................................
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● Quality / Quantity : .............................................................................................
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● Region : .............................................................................................
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● Severity Scale : .............................................................................................
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● Timming : .............................................................................................

Pemahaman & Penatalaksanaan Masalah Kesehatan : ............................................

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Obat-Obatan :
No Nama Obat Dosis Keterangan

Status Imunisasi : (Catat tanggal terbaru)

Tetanus, Difteri : .............................................. Influenza ...........................
Pneomovaks : ...........................................................................................
Alergi : (Catatan agen dan reaksi spesifik)
Obat-obatan : ...........................................................................................
Makanan : ...........................................................................................
Faktor Lingkungan : ...........................................................................................
Penyakit yang diderita :
Hipertensi ... Rhematoid ...Asthma ... Dimensia ... Lain-lain sebutkan :
.......................................................................................................................................

K. AKTIVITAS HIDUP SEHARI-HARI

Indeks Katz :A/B/C/D/E/F/G
Oksigenasi : ...........................................................................................
Cairan & Elektrolit : ...........................................................................................
Nutrisi : ...........................................................................................
 Eliminasi : ...........................................................................................
Aktivitas : ...........................................................................................
Istirahat & Tidur : ...........................................................................................
Personal Hygiene : ...........................................................................................
Seksual : ...........................................................................................
Rekreasi : ...........................................................................................
Psikologis : ...........................................................................................
● Persepsi Klien : .............................................................................................
● Konsep diri : .............................................................................................
● Emosi : .............................................................................................
● Adaptasi : .............................................................................................
● Mekanisme Pertahanan Diri : ................................................................................

L. TINJAUAN SISTEM
Keadaan umum : ..........................................................................................................
Tingkat kesadaran : kompos mentis, Apatis, Sumnolen, Suporus, Coma
GCS : membuka mata = , verbal = , psikomotor =
Tanda vital : nadi = X/menit RR = X/mnt, tensi = mmHg
1) Kepala : ...........................................................................................
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2) Mata, telinga, hidung : .................................................................................
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3) Leher : .................................................................................
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4) Dada dan Punggung : .................................................................................
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5) Abdomen & Pinggang : .................................................................................
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6) Ekstremitas atas & bawah : .................................................................................
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7) Sistem Imune : .................................................................................
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8) Genetalia : .................................................................................
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9) Sistem Reproduksi, termasuk cedera pada system reproduksi akibat aniaya
 seksual: ....................................................................................................................
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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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M. SCREENING MASALAH KESEHATAN LANJUT USIA
1) Short Portable Mental Status Questionner (SPSMQ) : ………………….
2) Mini-Mental State Examination (MMSE) : ………………….
3) Geriatric Depression Scale : …………………..
4) APGAR keluarga : ……………….
5) Morse Fall scale : ....................
6) Berg Balance Scale (BBS) : ....................
7) Mini Nutrition Assesment : ........................
8) The Pittsburgh Sleep Quality Index (PSQI) : ......................

N. DATA PENUNJANG
1) Laboratorium : .......................................................................................................
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2) Radiologi : .......................................................................................................
......................................................................................................................................
3) EKG : .......................................................................................................
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4) USG : .......................................................................................................
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5) CT_scan : .......................................................................................................
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6) Obat-obatan : .......................................................................................................
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II. ANALISA DATA

No Data Interpretasi Masalah
. (sign / Symptom) (Etiologi) (Problem)
1 2 3 4
 PRIORITAS MASALAH
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III. RENCANA KEPERAWATAN

No. Hari/ Diagnosa TUJUAN INTERVENSI RASIONAL
Tgl/Jam Perawatan

IV. IMPLEMENTASI
NO HARI/TGL NO. TINDAKAN CATATAN TTD/NAMA
PUKUL DX. KEPERAWATAN PERAWAT
PERKEMBANGAN
KEP.
(SOAP)
1 2 3 4 5