FORMAT PENGKAJIAN

ASUHAN KEPERAWATAN GERONTIK

A. PENGKAJIAN
Pengkajian dilaksanakan pada tanggal ……… bulan ……………… tahun ……….
Pada pukul ………….. yang bertempat di………………………………
1. Identitas Klien
a. Nama klien. .: (Inisial)
b. Tempat tanggal lahir ......................................................:

c. Pendidikan terakhir ........................................................:

d. Agama............................................................................:

e. Status perkawinan...........................................................:

f. TB / BB..........................................................................:
……………. Cm / …………… Kg.
IMT : ......................................................................................
g. Penampilan umum..........................................................:

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h. Ciri-ciri tubuh.................................................................:

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i. Alamat ...........................................................................:

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j. Orang yang dihubungi....................................................:

k. Hubungan dengan klien..................................................:

2. Riwayat Keluarga
a. Genogram
 b................................................................................................................................K
eterangan : ...............................................................................................................
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3. Riwayat pekerjaan :
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4. Riwayat lingkungan hidup :
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5. Riwayat rekreasi :
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6. Sistem pendukung yang digunakan :
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7. Deskripsi kekhususan / kebiasan :
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8. Status kesehatan saat ini :
……………………………………………………………..
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9. Status kesehatan masa lalu :
……………………………………………………………
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10. Kemampuan Klien

a. Pengkajian status fungsional dengan Indeks KATZs
Penilaian
No Kategori
Mandiri Bantuan
1 Mandi (Bathing)
2 Berpakaian (Dressing)
3 Kekamar mandi (Toileting)
4 Berpindah (Movement)
5 Kontinen (Continance)
6 Makan (Feeding)

Hasil penilaian ……………………………………………………………………...

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b. Psikologi klien
1) Persepsi klien terhadap penyakit :
……………………………………………..
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2) Konsep diri :
……………………………………………………………………
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3) Emosi :
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4) Kemampuan adaptasi :
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5) Mekanisme pertahanan diri :
…………………………………………………..
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c. Pengkajian status kognitif dan afektif dengan Short Portable Mental Status
Questionnaire (SPSMQ)
Jawaban
No Pertanyaan
Benar Salah
1 Tanggal berapakah hari ini?
2 Hari apakah sekarang ini?
 3 Apakah nama tempat ini?
4 Dimanakah alamat anda?
5 Berapakah usia anda saat ini?
6 Kapan anda lahir? (minimal tahun lahir)
7 Siapakah presiden Indonesia sekarang ini?
8 Siapakah presiden Indonesia sebelumnya?
9 Siapakah nama Ibu kandung anda?
10 Kurangi 3 dari 20 dan tetap pengurangan 3 dari setiap
angka baru, semua secara menurun

Hasil penilaian ……………………………………………………………………...

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d. Pengkajian status sosial dengan APGAR Scores
Jawaban
No Fungsi Uraian Kadang- Tidak
Selalu
Kadang Pernah
1 Adapta- Saya puas dengan perhatian
bility yang diberikan oleh anggota
keluarga kepada saya.
2 Partici- Saya puas dengan keluarga
pation yang membicarakan suatu
masalah dengan saya.
3 Growth Saya puas dengan keluarga
yang mendukung perubahan
peran dan emosi saya.
4 Affec- Saya puas dengan keluarga
tion yang menghargai saya.
5 Resolu- Saya puas dengan keluarga
tion yang menyediakan waktu
untuk bersama dengan saya.

Hasil penilaian ……………………………………………………………………...

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11. Pemeriksaan fisik

a. Keadaan umum :
…………………………………………………………………..
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b. Tingkat kesadaran : E =………….. M =………… V =………..
Kesimpulan : ............................................................................................................
c. TTV
TD : ……………. mmHg HR : …………. x / menit
RR : ……………. x / menit Suhu : …………. 0C
SpO2 : …………....
d. Massa tubuh
TB : ………… cm
BB : ………… Kg
IMT : …………
e. Kulit :
………………………………………………………………………………
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f. Ulkus decubitus :
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g. Kepala :
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h. Rambut dan kuku :

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i. Mata :
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j. Telinga :
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k. Hidung :
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l. Mulut dan gigi :
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m. Leher :
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n. Payudara :
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o. Sistem Cardiovaskuler :
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p. Sistem Pernafasan :
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q. Sistem Gastrointestinal :
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r. Anus dan genital :
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s. Sistem Perkemihan :
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t. Sistem Muskuloskeletal :
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u. Sistem Endokrin :
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v. Sistem Imun dan Hematologi :
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w. Sistem Reproduksi :
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x. Sistem Persyarafan :
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B. ANALISA DATA
Nama Klien : ……………………….. Alamat : ………………………..
Tanggal lahir : …………………………
Hari /
Data Problem Etiologi
Tanggal
DS:

DO:

DS:

DO:

C. DIAGNOSA
1.
2.

D. INTERVENSI
Nama Klien : ……………………….. Alamat : ………………………..
Tanggal lahir : …………………………
NIC
No Dx NOC Rasional TTD
Mayor Disarankan
1
2

E. IMPLEMENTASI
Nama Klien : ……………………….. Alamat : ………………………..
Tanggal lahir : …………………………
Waktu Dx Implementasi Respon TTD
S:

O:
F. EVALUASI
Hari / Tanggal Dx Evaluasi TTD
S:

O:

A:

P:
 S:

O:

A:

P:

TUGAS SUBMIT PALING LAMBAT HARI JUMAT TANGGAL 17 JUNI 2016

KE Email: waone_cuk@yahoo.co.id