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ASUHAN KEPERAWATAN GERONTIK
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DI RUANG ……………… RSUD ……………………………………
Nama Mahasiswa : ……………………………………
NIM : ……………………………………
Tempat Praktik : Ruang ……………………………
RSUD ……………………………
Tanggal Pengkajian : ……………………………… 2014
A. PENGKAJIAN
Pengkajian dilakukan pada Hari ………… Tanggal ……………………… 2014 di
Ruang ………… RSUD ………………………………… secara alloanamnesa dan
autoanamnesa.
1. IDENTITAS
a. Identitas Klien
Nama : ………………………………………………
Jenis Kelamin : ………………………………………………
Umur : ………………………………………………
Pendidikan Terakhir : ………………………………………………
Agama : ………………………………………………
Suku : ………………………………………………
Status Perkawinan : ………………………………………………
Pekerjaan : ………………………………………………
Alamat : ………………………………………………
Diagnosa medis : ………………………………………………
No RM : ………………………………………………
Tanggal masuk : ………………………………………………
b. Identitas Penanggungjawab
Nama : ………………………………………………
Umur : ………………………………………………
Jenis Kelamin : ………………………………………………
Agama : ………………………………………………
Suku : ………………………………………………
Hubungan dng pasien : ………………………………………………
Pekerjaan : ………………………………………………
2. RIWAYAT KESEHATAN
a. Keluhan Utama :
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b. Riwayat kesehatan sekarang :
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c. Riwayat kesehatan dahulu :
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d. Riwayat kesehatan keluarga :
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e. Genogram
Keterangan :
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3. POLA PENGKAJIAN FUNGSIONAL
a. Pola persepsi-Management Kesehatan
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b. Pola nutrisi
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c. Pola Eliminasi
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d. Pola latihan – Aktivitas
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INDEKS KATZ
No. Macam ADLSifat
Mandiri Tergantung1 Makan2 Kontinen ( BAB/BAK )3 Berpindah4 Mandi5 Ke kamar kecil6 Berpakaian
Keterangan :
A : Kemandirian dalam hal makan, kontinen (BAK/BAB), berpindah,
kekamar kecil, mandii dan berpakaian
B : Kemandirian dalam semua hal kecuali satu dari fungsi tersebut
C : Kemandirian dalam semua hal, kecuali mandi dan satu fungsi
tambahan
D : Kemandirian dalam semua hal, kecuali mandi, berpakaian,
kekamar kecil, dan satu fungsi tambahan
E : Kemandirian dalam semua hal kecuali mandi, berpakaian, kekamar
kecil, berpindah, dan satu fungsi tambahan
F : Ketergantungan keenam fungsi tersebut
Hasil pengkajian : ....................................................................................
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e. Pola kognitif perseptual
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Pengkajian Fungsi Kongnitif
No. ITEM PERTANYAAN BENAR SALAH
1 Jam berapa sekarang ?Jawaban :
2 Tahun berapa sekarang ?Jawaban :
3 Kapan bapak/ibu lahir ?Jawaban :
4 Berapa umur bapak/ibu sekarang ?Jawaban :
5 Dimana alamat bapak/ibu sekarang ?Jawaban :
6 Berapa jumlah anggota keluarga yang tinggal bersama bapak/ibu sekarang ?Jawaban :
7 Sejak kapan bapak masuk Rumah SakitJawaban :
8 Tahun berapa hari kemerdekaan indonesia ?Jawaban :
9 Siapa nama Presiden RI sekarang?Jawaban :
10 Coba hitung terbalik dari angka 20 ke 1?Jawaban :
JUMLAH BENAR
Keterangan :
Skor benar : 8 – 10 : Tidak ada gangguan
Skor benar : 0 – 7 : Ada gangguan
Hasil pengkajian : ....................................................................................
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f. Pola istirahat – tidur
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g. Pola Konsep Diri/Persepsi Diri
1) Gambaran diri (citra tubuh)
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2) Identitas
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3) Peran
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4) Ideal diri
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5) Harga diri
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h. Pola Peran dan Hubungan
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i. Pola Reproduksi / Seksual
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j. Pola Pertahanan Diri (Coping toleransi stress)
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Skala Depresi
1) Apakah anda sebenarnya puas dengan kehidupan anda ? ya / tidak
2) Apakah anda telah meninggalkan banyak kegiatan dan minat atau
kesenangan anda? ya / tidak
3) Apakah anda merasa kehidupan anda kosong? ya / tidak
4) Apakah anda sering merasa bosan? ya / tidak
5) Apakah anda mempunyai semangat yang baik setiap saat? ya / tidak
6) Apakah anda takut bahwa sesuatu yang buruk akan terjadi pada anda?
ya / tidak
7) Apakah anda merasa bahagia untuk sebagian besar hidup anda? ya /
tidak
8) Apakah anda sering merasa tidak berdaya? ya / tidak
9) Apakah anda lebih senang tinggal dirumah daripada keluar dan
mengerjakan sesuatu yang baru? ya / tidak
10) Apakah anda merasa mempunyai banyak masalah dengan daya ingat
anda dibanding kebanyakan orang? ya / tidak
11) Apakah anda pikir bahwa hidup anda sekarang ini menyenangkan?
ya / tidak
12) Apakah anda merasa tidak berharga seperti perasaan anda saat
ini? ya / tidak
13) Apakah anda merasa anda penuh semangat? ya / tidak
14) Apakah anda merasa bahwa keadaan anda tidak ada harapan? ya /
tidak
15) Apakah anda pikir bahwa orang lain lebih baik keadaannya daripada
anda? ya / tidak
Keterangan :
Skor : Hitung jumlah jawaban yang bercetak tebal dan huruf besar Setiap
jawaban bercetak tebal dan berhuruf besar mempunyai nilai 1
Skor 0 – 5 : Normal
Skor 5 – 9 : Depresi ringan sampai sedang
Skor 10 – 15 : Depresi Berat
Hasil pengkajian : ....................................................................................
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k. Pola Keyakinan Dan Nilai
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4. PEMERIKSAAN FISIK
a. Tanda – tanda Vital
TANDA-TANDA VITAL
HARI & TANGGAL
Hari :Tgl :
Hari :Tgl :
Hari :Tgl :
Tekanan Darah ……… mmHg ……… mmHg ……… mmHg
Nadi ……… x/menit ……… x/menit ……… x/menit
Respiratory Rate ……… x/menit ……… x/menit ……… x/menit
Suhu ……… 0C ……… 0C ……… 0C
b. Pemeriksaan head to toe
1) Kepala : ………………………………………………
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2) Mata : ………………………………………………
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3) Hidung : ………………………………………………
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4) Mulut dan tenggorokan : ………………………………………………
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5) Telinga : ………………………………………………
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6) Dada :
Thorak
I : ………………………………………………………………………
P : ………………………………………………………………………
P : ………………………………………………………………………
A : ………………………………………………………………………
Jantung
I : ………………………………………………………………………
P : ………………………………………………………………………
P : ………………………………………………………………………
A : ………………………………………………………………………
7) Abdomen :
I : ………………………………………………………………………
P : ………………………………………………………………………
P : ………………………………………………………………………
A : ………………………………………………………………………
8) Genetalia : ………………………………………………
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9) Integumen : ………………………………………………
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10) Ekstremitas : ………………………………………………
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5. DATA PENUNJANG
a. Laboratorium
Hari / Tanggal : ………………………………………………
Jenis Pemeriksaan HasilSatuan
Nilai Normal Ket.
b. Radiologi
Hari / Tanggal : ………………………………………………
c. Terapi
B. ANALISA DATA
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
No.HARI
TANGGALJAM
DATA FOKUS MASALAH ETIOLOGI
C. PERIORITAS DIAGNOSA KEPERAWATAN
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D. RENCANA TINDAKAN KEPERAWATAN
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
HARITANGGAL
JAM
No. DP
TUJUAN & KRITERIA HASIL(NOC)
INTERVENSI (NIC) Ttd.
E. TINDAKAN KEPERAWATAN
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
HARI & TANGGAL
PUKUL
No.DP
IMPLEMENTASI RESPON PASIEN Ttd.
F. EVALUASI
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
No.HARI
TANGGALJAM
DIAGNOSA KEPERAWATAN EVALUASI TTD