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 |
|
|
|
|
|
