Format Asuhan Keperawtan Pada Lanjut Usia

 

FORMAT ASUHAN KEPERAWATAN

PADA LANJUT USIA

 

Nama Mahasiswa   : ___________________________________

NIM                       : ___________________________________

 

A.    PENGKAJIAN

I.   IDENTITAS

1.   Lansia

Nama                                 : ____________________________________________

Alamat                               : ____________________________________________

Jenis Kelamin                     : ____________________________________________

Umur                                 : ____________________________________________

Status                                 : ____________________________________________

Agama                               : ____________________________________________

Suku                                   : ____________________________________________

Riwayat Pendidikan                        : ____________________________________________

Riwayat Pekerjaan             : ____________________________________________

Sumber Pendapatan           : ____________________________________________

Tempat tinggal sekarang    : ____________________________________________

Lama Tinggal                     : ____________________________________________

 

2.   Penanggung jawab

Nama                                 : ____________________________________________

Alamat                               : ____________________________________________

Hubungan dengan lansia   : ____________________________________________

No Telepon                       : ____________________________________________

 

 

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  : ___________________________________________

_________________________________________________________________

_________________________________________________________________

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

__________________________________________________________________________________________________________________________________

 

D.   Riwayat Kesehatan Keluarga

1.    Penyakit yang pernah diderita keluarga : ________________________________

_________________________________________________________________

_________________________________________________________________

2.    Genogram :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III.   STATUS FISIOLOGIS

A.   Pola 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   : _____________________________________________________

-          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 : ____________________________________

______________________________________________________________________________________________________________________________

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

___________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

 

 

B.   Pemeriksaan 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  : _______________________________________________________________

__________________________________________________________________________________________________________________________________________

 

 

 

9.      Payudara  : ­­­­­­­­­­­___________________________________________________________

________________________________________________________________________________________________________________________________________

10.  Abdomen : ___________________________________________________________

________________________________________________________________________________________________________________________________________

11.  Genetalia : ___________________________________________________________

________________________________________________________________________________________________________________________________________

12.  Ekstremitas : _________________________________________________________

________________________________________________________________________________________________________________________________________

13.  Integumen : __________________________________________________________

____________________________________________________________________

____________________________________________________________________

 

IV.           STATUS KOGNITIF

A.   Fungsi Kognitif (format terlampir) : ________________________________________

_____________________________________________________________________

 

V.     STATUS PSIKOSOSIAL DAN SPIRITUAL

A.   Psikologis

1.      Persepsi Lansia terhadap proses menua

_______________________________________________________________________________________________________________________________________________________________________________________________________________

2.      Harapan Lansia terhadap proses menua

_______________________________________________________________________________________________________________________________________________________________________________________________________________

3.      Status Depresi  (format terlampir) : _____________________________________

 

 

 

B.   Sosial

1.         Dukungan Keluarga (format 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 TEMPAT TINGGAL

A.     Kebersihan dan Kerapihan ruangan : _______________________________________

__________________________________________________________________________________________________________________________________________

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

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

                                                                       ______________,__________________

                                                                      

 

 

                                                                       (______________________)

 

 

 

B.     ANALISA DATA

NO	DATA	PROBLEM	ETIOLOGI

 

______________,__________________

                                                                      

 

 

                                                                       (______________________)

                     

C.     DAFTAR DIAGNOSA

NO	TANGGAL	DIAGNOSA KEPERAWATAN

 

______________,__________________

                                                                      

 

 

                                                                       (_______________________________)

                       

 

 

 

 

D.    RENCANA KEPERAWATAN

 

NO	TUJUAN	KRITERIA HASIL	INTERVENSI	RASIONAL

 

 

______________,__________________

                                                                      

 

 

                                                                       (_______________________________)

 

                       

E.  TINDAKAN KEPERAWATAN

 

NO	WAKTU	IMPLEMENTASI DAN RESPON	TTD

 

 

 

                         

F.  EVALUASI

 

NO	WAKTU	CATATAN PERKEMBANGAN	TTD