form pengkajian geriatri 2014

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PEMERINTAH KABUPATEN LUMAJANG

DINAS KESEHATAN

AKADEMI KEPERAWATAN

JL. BRIGJEN KATAMSO TELP (0334) 882262 LUMAJANG

FORMAT PENGKAJIAN LANSIA

KEPERAWATAN GERONTIK

NAMA MAHASISWA

N I M

TINGKAT / SEMESTER

TANGGAL PRAKTIK

TEMPAT PRAKTIK: ..........................................................................................................

: ..........................................................................................................

: ..........................................................................................................

: ..........................................................................................................

: ..........................................................................................................

I. PENGKAJIAN

A. Data Biografi

1. Nama:.............................................................................................

2. Jenis kelamin:L / P

3. Golongan darah:O / A / B / AB

4. Tempat & tanggal lahir:.............................................................................................

5. Pendidikan terakhir:SD / SLTP / SLTA / D I / D II / D III / D IV / S1 / S2 / S3

6. Agama:Islam/Protestan/Katolik/Hindu/Budha/Konghucu7. Status perkawinan:Kawin / Belum / Janda / Duda (Cerai : hidup / mati)

8. Tinggi badan/berat badan:.......... cm .......... kg

9. Penampilan:....................................... Ciri-ciri tubuh : ...........................

10. Alamat:.............................................................................................

11. Orang yang mudah dihubungi:.............................................................................................

12. Alamat & telepon:.............................................................................................

B. Riwayat Keluarga

Genogram :

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

a. Pemukiman

Luas bangunan = .

Bentuk

asrama

petak

Jenis bangunan permanent

semi permanent

Atap rumah

genteng

seng

asbes

Dinding

tembok

gedhek

Lantai

semen

keramik

tanah

Ventilasi

< 10 % luas lantai

cahaya kurang

Kebersihan

kurang

b. Sanitasi

Air bersih

PDAM

sumur

Jarak jamban dg sumur

< 10 meter

Sampah

ditanam dibakar

diambil petugas

Binatang pengerat

tikus

kucing

c. Fasilitas

Peternakan

ada

tidak ada

Pekerangan

ada

tidak ada

Sarana OLRA

ada

tidak ada

Taman

ada

tidak ada

Ruang pertemuan

ada

tidak ada

Sarana hiburan

ada

tidak ada

Kondisi jalan

rata

tanjakan tidak rata 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 : .....................................................................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:......................................................................................................

......................................................................................................

......................................................................................................

e. Timing: ................................................................................................

4. Pemahaman dan penatalaksanaan masalah kesehatan :

................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................

5. Obat-obatan

No.Nama obatDosisKet

6. Status imunisasi (catat tanggal terbaru)

a. Tetanus, 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/ LAIN-LAIN2. Nutrisi: