format laporan asuhan keperawatan gerontik

7/23/2019 Format Laporan Asuhan Keperawatan Gerontik

http://slidepdf.com/reader/full/format-laporan-asuhan-keperawatan-gerontik 1/19

LAPORAN ASUHAN KEPERAWATAN GERONTIK

PADA LANSIA ……………………………………………………………

DI RUANG GANDASTURI RSUP SANGLAH

TANGGAL ……………………….. 2014

I. PENGKAJIAN/PENGUMPULAN DATA

A. IDENTITAS/DATA BIOGRAFI KLIEN

1. Nama : …………………………………………………

2. No. Rekam Medis : …………………………………………………

3. e!is Ke"ami! : …………………………………………………

#. Tem$a% Ta!&&a" La'i( : …………………………………………………

). *m+( : …………………………………………………

,. A&ama : …………………………………………………

-. S%a%+s e(kai!a! : …………………………………………………

0. eke(aa! : …………………………………………………

. e!didika! Te(ak'i( : …………………………………………………

1. A"ama% R+ma' : …………………………………………………

11. O(a!& 4a!& deka% di'+5+!&i :…………………………………………………

12. 6+5+!&a! de!&a! k"ie! : …………………………………………………

13. Ta!&&a" mas+k ke RS/a!%i 7(ed'a : …………………………………………………

B. KEL*6AN *TAMA

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8. RI7A9AT KESE6ATAN SAAT INI

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D. RI7A9AT KESE6ATAN MASA LAL*

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GENOGRAM

E. ALASAN TINGGAL DI ANTI

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F. RI7A9AT EN9AKIT KEL*ARGA

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G. RI7A9AT EKERAAN

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6. RI7A9AT LINGK*NGAN 6ID*

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I. RI7A9AT REKREASI

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. SISTEM END*K*NG

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K. SIRIT*AL/K*LT*RAL

1. e"aksa!aa! i5ada'

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2. Ke4aki!a! %e!%a!& kese'a%a!

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L. EMERIKSAAN FISIK

Ti!a+a! Sis%em

1. Keadaa! +m+m : ………………………………………………………

2. Ti!&ka% kesada(a! :

8om$osme%is/A$a%is/Som!o"e!/S+$o(/8oma;

3. G"as&o 8oma S<a"e : E…..= >…..= M…….

#. Ta!da?Ta!da >i%a" :a. S+'+ : ……………………………………..

5. Nadi : ……………………………………..

<. Teka!a! da(a' : ………………………….

d. e(!a@asa! : ………………………………

). Ti!&&i 5ada! : …………………………………

,. Be(a% 5ada! : ………………………………….

-. IMT : ………………………………………….

0. Sis%em Ka(dioask+"e( :

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. Sis%em e(!a@asa!

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1. Sis%em I!%e&+me!

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11. Sis%em e(kemi'a!

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12. Sis%em M+sk+"oske"e%a"

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13. Sis%em E!dok(i!

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1#. Sis%em Im+!

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1). Sis%em Gas%(oi!%es%i!a"

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1,. Sis%em Re$(od+ksi

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1-. Sis%em e(s4a(a@a!

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M.ENGKAIAN SIKOSOSIAL DAN SIRIT*AL

1. sikososia"

e"aska! kemam$+a! sosia"isasi k"ie! $ada saa% seka(a!&=sika$ k"ie! $ada o(a!& "ai!=

'a(a$a!?'a(a$a! k"ie! da"am me"ak+ka! sosia"isasi

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2. Ide!%i@ikasi masa"a' emosio!a"

e(%a!4aa! %a'a$ 1

•

A$aka' k"ie! me!&a"ami kes+"i%a! %id+(…………………………………………………………………………………………

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•A$aka' k"ie! se(i!& me(asa &e"isa'

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•A$aka' k"ie! se(i!& m+(+!& da! me!a!&is se!di(i

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•A$aka' k"ie! se(i!& as?as a%a+ k'aa%i(

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e(%a!4aa! %a'a$ 2

• Ke"+'a! "e5i' da(i 3 5+"a! a%a+ "e5i' da(i sa%+ ka"i da"am sa%+ 5+"a!

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• Ada a%a+ 5a!4ak $iki(a!

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• Ada masa"a' a%a+ &a!&&+a! de!&a! ke"+a(&a "ai!

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• Me!&&+!aka! o5a% %id+(/$e!e!a!& a%as a!+(a! dok%e(

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• 8e!de(+!& me!&+(+!& di(i

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Bi"a "e5i' da(i sa%+ a%a+ sama 1 aa5a! C4a MASALA6 EMOSIONAL OSITIF ;



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3. S$i(i%+a"

Kai a&ama= ke&ia%a! kea&amaa!= ko!se$/ke4ai!a! k"ie! %e!%a!& kema%ia!= 'a(a$a!?'a(a$a! k"ie!= da! "ai!?"ai!

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N. ADL Activity Daily Living ;

e!&kaia! @+!&sio!a" 5e(dasa(ka! INDEKS KAT

e!&kaia! i!i me"i$+%i o5sse(asi kemam$+a! k"ie! +!%+k me"ak+ka! ak%ii%as

ke'd+$a! se'a(i?'a(i/ Activity Daily Living

1. INDEKS KAT

Te(mas+k/ka%a&o(i ma!aka' k"ie!

A. Ma!di(i da"am maka!= ko!%i!e!sia= BAB/BAK;= me!&&+!aka! $akaia!= $e(&i ke

%oi"e%=5e($i!da' da! ma!diB. Ma!di(i sem+a!4a ke<+a"i sa"a' sa%+ da(i @+!&si di a%as

8. Ma!di(i ke<+a"i ma!di da! sa"a' sa%+ @+!&si di a%as

D. Ma!di(i= ke<+a"i ma!di= 5e($akaia!= da! sa"a' sa%+ da(i @+!&si di a%as

E. Ma!di(i ke<+a"i= ma!di= 5e($akaia!= ke %oi"e%= da! sa%+ @+!&si 4a!& "ai!

F. Ma!di(i ke<+a"i= 5e($akaia!= ke %oi"e%= 5e($i!da' da! sa%+ @+!&si 4a!& "ai!

G. Ke%e(&a!%+!&a! +!%+k sem+a @+!&si dia%as

6. Lai!?"ai! ke%e(&a!%+!&a! sediki%!4a d+a @+!&si %e%a$i %idak da$a% dik"asi@ikasika!

se5a&ai A= B= 8= D= E= F G;

Ke%e(a!&a!:

Ma!di(i 5e(a(%i %a!$a $e!&aasa!= $e!&a(a'a! a%a+ 5a!%+a! e@ek%i@ da(i o(a!& "ai!=

seseo(a!& 4a!& me!o"ak +!%+k me"ak+ka! s+a%+ @+!&si dia!&&a$ %idak me"ak+ka!

@+!&si meski$+! dia dia!&&a$ mam$+

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H. MODIFIKASI DARI BART6EL INDEKSTe(mas+k 4a!& ma!aka' k"ie!

NO KRITERIADENGAN

BANTUANMANDIRI KETERANGAN

1 Maka!

) 1

F(ek+e!si:

+m"a':

e!is:

2 Mi!+m

) 1

F(ek+e!si:

+m"a':

e!is:

3 Be($i!da' da(i k+(si (oda ke%em$a% %id+( a%a+ se5a"ik!4a

)?1 1)

# e(so!a" %oi"e% <+<i m+ka=

me!4isi( (am5+%= &osok &i&i; )

F(ek+e!si:

) Ke"+a( mas+k %oi"e% me!<+<i

$akaia!= me!4eka %+5+'=

me!4i(am;

) 1

, Ma!di ) 1)

- a"a! di $e(m+kaa! da%a( )

F(ek+e!si:

0 Naik %+(+! %a!&&a ) 1 Me!&e!aka! $akaia! ) 1

1 Ko!%(o" 5oe" BAB;) 1

F(ek+e!si:

7a(!a:

11 Ko!%(o" 5"adde( BAK;) 1

F(ek+e!si:

7a(!a:

Ketera!a "

13 : Ma!di(i

,)?12) : Ke%e(&a!%+!&a! se5a&ia!

, : Ke%e(&a!%+!&a! %o%a"

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O. ENGKAIAN STAT*S MENTAL GERONTIK

1. Ide!%i@ikasi %i!&ka% i!%e"ek%+a" de!&a! Short Protable Mental

Status Questioner (SPMSQ)

I!s%(+ksi :

A+ka! $e(%a!4aa! 1?1 $ada da@%a( i!i da! <a%a% sem+a aa5a!

8a%a% +m"a' kesa"a'a! %o%a" 5e(dasa(ka! %o%a" kesa"a'a! 5e(dasa(ka! 1 $e(%a!4aa!

N# PERTAN$AAN BENAR SALAH

1 Ta!&&a" 5e(a$a 'a(i i!i

2 6a(i a$a seka(a!& i!i

3 A$a !ama %em$a% i!i

# A"ama% a!da ) Be(a$a +m+( a!da

, Ka$a! a!da "a'i( mi!ima"

%a'+! "a'i(;

- Sia$a $(eside! I!do!esia

seka(a!&

0 Sia$a $(eside! I!do!esia

se5e"+m!4a

Sia$a !ama i5+ a!da

1 K+(a!&i 3 da(i 2 da! %e%a$

$e!&+(a!&a! 3 da(i se%ia$ a!&ka 5a(+= sem+a se<a(a me!+(+!

+m"a' Kesa"a'a! To%a"

Pe%&a%a SPMS'"

Sa"a' ?3 : @+!&si i!%e"ek%+a" +%+'

Sa"a' #?) : ke(+saka! i!%e"ek%+a" (i!&a!

Sa"a' ,?0 : ke(+saka! i!%e"ek%+a" seda!&

Sa"a' ?1 : ke(+saka! i!%e"ek%+a" 5e(a%

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2. Ide!%i@ikasi as$ek ko&!i%i@ da(i @+!&si me!%a" de!&a! me!&&+!aka! MMSE Mini

Mental Status Exam;

N

O

A()e*

K#!%t%+

N%&a

%

Ma,

Na-a K&%e Kr%ter%a

1 O(ie!%asi ) Me!4e5+%ka! de!&a! 5e!a(

oTa'+!

oM+sim

oTa!&&a"

o6a(i

oB+"a!

2 O(ie!%asi ) Dima!a ki%a seka(a!&

o Ne&a(a.............................

o(oi!si............................

oKo%a.................................

oR+ma' saki%....................

oa!%i (eda= 7isma........

3 Re&is%(asi 3 Se5+%ka! 3 o54ek o"e'

$eme(iksa; 1 de%ik +!%+k

me!&a%aka! masi!&?masi!&

o5ek. Kem+dia! %a!4aka!

ke$ada k"ie! ke%i&a o54ek %adi

+!%+k dise5+%ka!;

oO54ek..............................

oO54ek..............................

oO54ek..............................

# e('a%ia!

da!

ka"k+"asi

) Mi!%a k"ie! +!%+k mem+"ai da(i

a!&ka 1 kem+dia! dik+(a!&i -

sam$ai ) ka"i:

o3

o0,

o-

o-2

o,)

) Me!&i!&a% 3 Mi!%a k"ie! +!%+k me!&+"a!&i

ke%i&a o54ek $ada !o 2

(e&is%(asi; %adi= 5i"a 5e!a( 1 $oi!%

+!%+k masi!&?masi!& o54ek

, Ba'asa T+!+kka! $ada k"ie! s+a%+ 5e!da

da! %a!4aka! !ama!4a $ada k"ie!

misa" am %a!&a! a%a+ $e!si";



Mi!%a ke$ada k"ie! +!%+k

me!&+"a!& ka%a 5e(ik+%: C%ak ada=

ika= da!= a%a+= %e%a$i. Bi"a 5e!a(=

!i"ai 2 $oi!%. Bi"a $e(!4a%aa!

5e!a( 2?3 5+a'= misa"!4a : %idakada= %e%a$i maka !i"ai 1 $oi!%.

Mi!%a k"ie! +!%+k me!&ik+%i

$e(i!%a' 5e(ik+% 4a!& %e(di(i 4a!&

%e(di(i da(i 3 "a!&ka': CAm5i"

ke(%as di %a!&a! a!da= "i$a% d+a

da! %a(+' di "a!%ai

o Am5i" ke(%as

o Li$a% d+a

o Ta(+' di"a!%ai

e(i!%a'ka! $ada k"ie! +!%+k 'a"

5e(ik+% 5i"a ak%ii%as ses+ai

$e(i!%a' !i"ai 1 $oi!%;

o T+%+$ ma%a

e(i!%a'ka! $ada k"ie! +!%+k

me!+"is sa%+ ka"ima% da!

me!4a"i! &am5a( o T+"is sa%+ ka"ima%

o Me!4a"i! &am5a(

To%a" Ni"ai

Iter)reta(% a(%&"

23 : As$ek ko&!i%i@ da(i @+!&si me!%a" 5aik

10.22: Ke(+saka! as$ek @+!&si me!%a" (i!&a!

J1- : Te(da$a% ke(+saka! as$ek @+!&si me!%a"

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. INFORMASI EN*NANG

1. La5o(a%o(i+m : …………………………………………………………………

2. Radio"o&i : …………………………………………………………………

3. Dia&!osa medis :

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#. Te(a$i medis= o5a% da! "ai!?"ai! :

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II. ANALISA DATA

No.

TGL

/

AM

Da%a E%io"o&i Masa"a' Ko"a5o(a%i@

Ke$e(aa%a!

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III. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS MASALAH

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I. RENANA KEPERAWATAN

No. Dia&!osa T++a! I!%e(e!si Rasio!a"

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. IMPLEMENTASI

6a(i /

%&" /

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No.

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Ti!daka! ke$e(aa%a! Ea"+asi T%d

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I. EALUASI

No. 6a(i/

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No.

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Ea"+asi T%d

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DATAR PUSTAKA

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De!$asa(=…………………………………21#Ma'asisa =

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format laporan asuhan keperawatan gerontik

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