FORMAT PENGKAJIAN

ASUHAN KEPERAWATAN GERONTIK INDIVIDU

A. Karakteristik Demografi
1. Identitas Diri Klien
Nama Lengkap : ..............................................................................
Tempat/Tgl Lahir : ..............................................................................
Jenis Kelamin : ..............................................................................
Status Perkawinan : ..............................................................................
Agama : ..............................................................................
Suku Bangsa : ..............................................................................
Pendidikan Terakhir: ..............................................................................
Diagnosa Medis (Bila ada) : ...................................................................
Alamat : ..............................................................................
2. Keluarga atau orang lain yang penting/Dekat yang dapat dihubungi
Nama : .................................................................
Alamat : .................................................................
No.Telepon : .................................................................
Hubungan dengan klien : ................................................................
GENOGRAM
3. Alasan utama datang ke RS/Menghuni PSTW :
.....................................................................................................................
.....................................................................................................................
4. Keluhan utama saat ini :
......................................................................................................................
......................................................................................................................
5. Riwayat Pekerjaan dan status Ekonomi
Pekerjaan saat ini : .................................................................
Pekerjaan sebelumnya : .................................................................
Sumber Pendapatan : .................................................................
Kecukupan Pendapatan : .................................................................
6. Aktivitas Rekreasi
Hobi : .................................................................
Berpergian/wisata : .................................................................
Keanggotaan organisasi : .................................................................
Lain – Lain : .................................................................
7. Riwayat Keluarga
a. Saudara Kandung
Nama Keadaan Saat ini Keterangan
1
2
3
4
5

b. Riwayat Kematian dalam Keluarga (1 tahun terakhir) :

Nama : ......................................................................
Umur : ......................................................................
Penyebab Kematian : ......................................................................
c. Kunjungan keluarga : ......................................................................
d. Riwayat Alergi : ......................................................................

B. Pola Kebiasaan sehari-hari

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1. Nutrisi
Frekuensi makan : .................................................................................
Nafsu makan : .................................................................................
Jenis makanan : .................................................................................
Kebiasan sebelum makan : ...........................................................................
Makanan yang tidak disukai : .......................................................................
Alergi terhadap makanan : ........................................................................
Pantangan makan : .......................................................................
Keluhan yang berhubungan dengan makan : ...............................................
.......................................................................................................................
2. Eliminasi
a. BAK
Frekuensi dan waktu : .............................................................................
Kebiasaan BAK pada malam hari : .........................................................
Keluhan yang berhubungan dengan BAK : .............................................
b. BAB
Frekuensi dan waktu : ..............................................................................
Konsistensi : .............................................................................
Keluhan yang berhubungan dengan BAB : ..............................................
..................................................................................................................
Pengalaman memakai Laxanti/pencahar ..................................................
...................................................................................................................
3. Personal Hiegene
a. Mandi
Frekuensi dan waktu mandi : ..................................................................
Pemakaian sabun (ya/tidak) : ...................................................................
b. Oral Hiegene
Frekuensi dan waktu gosok gigi : ............................................................
Menggunakan pasta gigi : ............................................................
c. Cuci Rambut
Frekuensi : ..................................................................................
Penggunaan shampo (ya/tidak) : ..............................................................
d. Kuku dan Tangan
Frekuensi gunting kuku : ........................................................................
Kebiasaan mencuci tangan pakai sabun : ................................................
4. Istirahat dan tidur
Lama tidur malam : .................................................................................
Tidur siang : .................................................................................
Keluhan yang berhubungan dengan tidur : ...................................................
.......................................................................................................................
5. Kebiasaan mengisi waktu luang
a. Olahraga : ..................................................................................
b. Nonton TV : ...................................................................................
c. Berkebun/memasak : ................................................................................
d. Lain – Lain : ...................................................................................
6. Kebiasaan yang mempengaruhi kesehatan
(jenis/frekuensi/jumlah/lama pakai)
a. Merokok (ya/tidak) : .........................................................................
b. Minuman Keras (ya/tidak) : ........................................................................
c. Ketergantungan terhadap obat (ya/tidak) : .................................................

7. Uraian kronologis kegiatan sehari-hari

Jenis kegiatan Lama waktu untuk setiap kegiatan
1.
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 2.
3.
4.
5.

C. Status Kesehatan
1. Status Kesehatan Saat Ini
a. Keluhan utama dalam 1 tahun terakhir : .................................................
.................................................................................................................
b. Gejala yang dirasakan : ...........................................................................
..................................................................................................................
c. Faktor pencetus : ......................................................................................
..................................................................................................................
d. Timbulnya Keluhan : ( ) Mendadak ( ) Bertahap
e. Waktu mulai timbulnya keluhan : ...........................................................
.................................................................................................................
f. Upaya mengatasi
Pergi ke RS/Klinikpengobatan/dokter praktik
Pergi ke bidan/perawat
Mengonsumsi obat-obatan sendiri
Mengonsumsi obat-oabatan tradisional
Lain –lain ...........................................................................................
2. Riwayat Kesehatan Masa lalu
a. Penyakit yang pernah diderita : ..........................................................
.............................................................................................................
b. Riwayat alergi (oabat, makanan, binatang, debu, dan lain-lain)
.............................................................................................................
c. Riwayat Kecelakaan : .........................................................................
.............................................................................................................
d. Riwayat dirawat di rumah sakit : ........................................................
.............................................................................................................
e. Riwayat pemakaian Obat : .................................................................
............................................................................................................
3. Pengkajian/Pemriksaan Fisik (Observasi, pengukuran, auskultasi, perkusi dan
palpasi)
a. Keadaaan umum (TTV) : .....................................................................
..............................................................................................................
b. Nyeri : Skala nyeri
c. Status Gizi : BB Saat ini : kg TB ...... cm
d. BMI : .............................................................................................
[] Gizi cukup
[] Gizi Lebih
[] Gizi Kurang
e. Personal Hyiene : ....................................................................
f. Rambut : .............................................................................................
..............................................................................................................
g. Mata : ...................................................................................................
..............................................................................................................
h. Telinga : ...............................................................................................
...............................................................................................................
i. Mulut, gigi, dan bibir : ..........................................................................
...............................................................................................................
j. Dada : ....................................................................................................

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 ...............................................................................................................
k. Abdomen : ............................................................................................
...............................................................................................................
l. Kulit : ....................................................................................................
...............................................................................................................

m. Ekstremitas atas : ..................................................................................

...............................................................................................................
n. Ekstremitasi Bawah : ............................................................................
...............................................................................................................
D. Hasil Pengkajian Khusus (Format Terlampir)
1. Masalah kesehtan kronis
.........................................................................................................................
2. Fungsi Kognitif
.........................................................................................................................
3. Status Fungsional
..........................................................................................................................
4. Status psikologis (Skala depresi)
..........................................................................................................................
5. Dukungan keluarga
.........................................................................................................................
E. Lingkungan Tempat Tinggal
1. Kebersiahan dan kerapihan ruangan : ............................................................
..........................................................................................................................
2. Penerangan : .................................................................................................
...........................................................................................................................
3. Sirkulasi udara : .............................................................................................
...........................................................................................................................
4. Keadaan kamar mandi dan WC : ...................................................................
...........................................................................................................................
5. Pembuangan air kotor : ..................................................................................
...........................................................................................................................
6. Sumber air minum : .......................................................................................
...........................................................................................................................
7. Pembungan sampah : .....................................................................................
............................................................................................................................
8. Sumber Pencemaran : ....................................................................................
...........................................................................................................................
9. Penataan halaman (kalau ada) : ......................................................................
............................................................................................................................
10. Privasi : .........................................................................................................
............................................................................................................................
11. Risiko injury : ...............................................................................................
..........................................................................................................................
A. Analisa data
No. Data Etiologi problem
DS :
DO:

B. Diagnosa keperawatan
C. Perencanaan tindakan keperawatan
No. Waktu Diagnosa Tujuan Intervensi Rasional TTD
(Hari/Tgl/Jam) keperawatan

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1.
2.
3.

D. Pelaksanaan tindakan keperawatan (IMPLEMENTASI)

No. Waktu Diagnosa Implementasi Evaluasi TTD
(Hari/Tgl/Jam) keperawatan
1. S:
O:

E. Evaluasi Formatif
No. Waktu Diagnosa Evaluasi TTD
(Hari/Tgl/Jam) keperawatan
S:
O:
A:
P:
F. Evaluasi Sumatif
No. Waktu Diagnosa Evaluasi TTD
(Hari/Tgl/Jam) keperawatan
S:
O:
A:
P:

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