Pengkajian Gerontik

A. PENGKAJIAN
1. BIODATA
Nama :___________________________________________________
Jenis Kelamin :___________________________________________________
Umur :___________________________________________________
Status Perkawinan :___________________________________________________
Pekerjaan :___________________________________________________
Agama :___________________________________________________
Pendidikan Terakhir :___________________________________________________
Alamat :___________________________________________________
Tanggal MRS :___________________________________________________
Tanggal Pengkajian :___________________________________________________
Diagnosa Medis :___________________________________________________

2. RIWAYAT KESEHATAN
a. Keluhan Utama
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b. Riwayat Penyakit Sekarang
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c. Riwayat Kesehtan Yang Lalu
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d. Riwayat Kesehtan Keluarga
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3. POLA AKTIVITAS SEHARI-HARI
a. Pola Tidur / Istirahat
Sebelum Sakit :___________________________________________________
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Saat Sakit :___________________________________________________
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b. Pola Eliminasi
Sebelum Sakit :___________________________________________________
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Saat Sakit :___________________________________________________
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c. Pola Makan dan Minum
Sebelum Sakit :___________________________________________________
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Saat Sakit :___________________________________________________
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d. Kebersihan Diri
Sebelum Sakit :___________________________________________________
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Saat Sakit :___________________________________________________
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e. Pola Kegiatan atau Aktivitas
Sebelum Sakit :___________________________________________________
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Saat Sakit :___________________________________________________
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 f. Kegiatan mandiri

No Kemampuan perawatan diri Independen Bantun alat

1. Makan/minum
2. Mandi
3. Berpakaian
4. Ke WC
5. Transfering/berpindah
6. Ambulasi

g. Penggunaan Bahan yang Merusak Kesehatan

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h. Riwayat Alergi
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4. DATA PSIKOSOSIAL
a. Pola Komunikasi
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b. Orang Yang Paling Dekat Dengan Pasien
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c. Hubungan Dengan Orang Lain
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d. Data Kognitif
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5. DATA SPIRITUAL
a. Ketaatan Beribadah
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b. Keyakinan Terhadap Sehat dan Sakit
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6. PEMERIKSAAN FISIK
a. Kesan Umum
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b. Tanda-tanda Vital
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c. Pemeriksaan Kepala dan Leher
- Kepala :_________________________________________________
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- Wajah :_________________________________________________
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- Mata :_________________________________________________
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- Hidung :_________________________________________________
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- Mulut dan Faring :_________________________________________________
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d. Pemeriksaan Integumen / Kulit
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e. Pemeriksaan Thorax dan Dada
- Inspeksi :____________________________________________________
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- Palpasi :____________________________________________________
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- Perkusi :____________________________________________________
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- Auskultasi :____________________________________________________
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- Pemeriksaan Jantung :_____________________________________________
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f. Pemeriksaan Abdomen
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g. Pemeriksaan Muskuloskeletal
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h. Pemeriksaan Neurologis
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7. PEMERIKSAAN PENUNJANG
a. Laboratorium
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b. Foto Rontgen
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8. PENATALAKSANAAN DAN TERAPI
a. Therapi
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b. Penatalaksanaan Perawatan
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B. ANALISA DATA
Tanggal Data Penunjang Masalah Kemungkinan Penyebab
C. DIAGNOSA KEPERAWATAN
NO Tanggal Muncul Diagnosa Keperawatan
D. RENCANA ASUHAN KEPERAWATAN
NO DIAGNOSA TUJUAN / KRITERIA
RENCANA TINDAKAN RASIONAL TT
Tanggal KEPERAWATAN STANDAR
E. TINDAKAN KEPERAWATAN
NO NO. DIAGNOSA TANGGAL/JAM TINDAKAN KEPERAWATAN TT

F. EVALUASI
Tanggal / NO. DX CATATAN PERKEMBANGAN