Format Pengkajian Keperawatan Gerontik

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FORMULIR PENGKAJIAN ASUHAN KEPERAWATAN GERONTIK STIKES HANG TUAH SURABAYA

I.

PENGKAJIAN A. Data Biografi 1. Nama 2. Jenis kelamin 3. Golongan darah 4. Tempat & tanggal lahir 5. Pendidikan terakhir 6. Agama 7. Status perkawinan 8. Tinggi badan/berat badan 9. Penampilan 10. Alamat 11. Orang yang mudah dihubungi 12. Alamat & telepon B. Riwayat Keluarga Genogram :

: : : : : : : : : : : :

............................................................................................. L/P O / A / B / AB ............................................................................................. SD / SLTP / SLTA / D I / D II / D III / D IV / S1 / S2 / S3 Islam/Protestan/Katolik/Hindu/Budha/Koghucu/LL Kawin / Belum / Janda / Duda (Cerai : hidup / mati) .......... cm .......... kg ....................................... Ciri-ciri tubuh : ........................... ............................................................................................. ............................................................................................. .............................................................................................

Keterangan :

C. Riwayat Pekerjaan 1. Pekerjaan saat ini : ...................................................................................................... 2. Alamat pekerjaan : ...................................................... jarak dari rumah ............. km 3. Alat transportasi : ...................................................................................................... 4. Pekerjaan sebelumnya : ...................................................... jarak dari rumah ............. km 5. Alat transportasi : ...................................................................................................... 6. Sumber-sumber pendapatan dan kecukupan terhadap kebutuhan : .........................................

................................................................................................................................................... ................................................................................................................................................... D. Riwayat Lingkungan Hidup 1. Type tempat tinggal : ......................................................................................................... 2. Jumlah kamar : ............... Jumlah tongkat : ............... 3. Kondisi tempat tinggal : ......................................................................................................... 4. Jumlah orang yang tinggal di rumah : Laki-laki = .......... orang / Perempuan = ........... orang 5. Derajat privasi : ......................................................................................................... 6. Tetangga terdekat : ......................................................................................................... 7. Alamat dan telepon : ......................................................................................................... E. Riwayat Rekreasi 1. Hobby/minat : ............................................................................................. 2. Keanggotaan dalam organisasi : ............................................................................................. 3. Liburan/perjalanan : ............................................................................................. F. Sistem Pendukung 1. Perawat/bidan/dokter/fisioterapi : .................................................. jaraknya .................. km 2. Rumah sakit : .................................................. jaraknya .................. km 3. Klinik : .................................................. jaraknya .................. km 4. Pelayanan kesehatan di rumah : .......................................................................................... 5. Makanan yang dihantarkan : .......................................................................................... 6. Perawatan sehari-hari yang dilakukan keluarga : ..................................................................... 7. Lain-lain : .......................................................................................... G. Deskripsi Kekhususan 1. Kebiasaan ritual : ..................................................................................................................... 2. Yang lainnya : ..................................................................................................................... H. Status Kesehatan 1. Status kesehatan umum selama setahun yang lalu : ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... 2. Status kesehatan umum selama 5 tahun yang lalu : ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... 3. Keluhan utama : a. Provokative/paliative : ...................................................................................................... ...................................................................................................... ...................................................................................................... b. Quality/quantity : ...................................................................................................... ...................................................................................................... ...................................................................................................... c. Region : ...................................................................................................... ...................................................................................................... ...................................................................................................... d. Severity Scale : ...................................................................................................... ...................................................................................................... ...................................................................................................... 4. Pemahaman dan penatalaksanaan masalah kesehatan : ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

5. Obat-obatan No.

Nama obat

Dosis

Ket

6. Status imunisasi (catat tanggal terbaru) a. Tetaus, difteri : .................................................................................................................. b. Influensa : .................................................................................................................. c. Pneumovaks : .................................................................................................................. d. Lain-lain : .................................................................................................................. 7. Alergi (catatan agen dan reaksi spesifik) a. Obat-obatan : ......................................................................................................... b. Makanan : ......................................................................................................... c. Faktor lingkungan : ......................................................................................................... 8. Penyakit yang diderita ( ) Hipertensi ( ) Rheumatoid ( ) Asthma ( ) Dimensia Lain-lain : sebutkan .................................................................................................................. I. Aktivitas Hidup Sehari-hari (ADL) 1. Indeks Katz : A/B/C/D/E/F/G 2. Oksigenasi : ............................................................................................................... 3. Cairan & elektrolit : ............................................................................................................... 4. Nutrisi : ............................................................................................................... 5. Eliminasi : ............................................................................................................... 6. Aktivitas : ...........................................................................................