format pengkajian keperawatan gerontik

34
FORMULIR PENGKAJIAN ASUHAN KEPERAWATAN GERONTIK STIKES HANG TUAH SURABAYA 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/Koghucu/LL 7. 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 :

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Page 1: Format Pengkajian Keperawatan Gerontik

FORMULIR PENGKAJIAN

ASUHAN KEPERAWATAN GERONTIK

STIKES HANG TUAH SURABAYA

I. PENGKAJIANA. Data Biografi

1. Nama : .............................................................................................2. Jenis kelamin : L / P3. Golongan darah : O / A / B / AB4. Tempat & tanggal lahir : .............................................................................................5. Pendidikan terakhir : SD / SLTP / SLTA / D I / D II / D III / D IV / S1 / S2 / S36. Agama : Islam/Protestan/Katolik/Hindu/Budha/Koghucu/LL7. Status perkawinan : Kawin / Belum / Janda / Duda (Cerai : hidup / mati)8. Tinggi badan/berat badan : .......... cm .......... kg9. Penampilan : ....................................... Ciri-ciri tubuh : ...........................10. Alamat : .............................................................................................11. Orang yang mudah dihubungi : .............................................................................................12. Alamat & telepon : .............................................................................................

B. Riwayat KeluargaGenogram :

Keterangan :

C. Riwayat Pekerjaan1. Pekerjaan saat ini : ......................................................................................................2. Alamat pekerjaan : ...................................................... jarak dari rumah ............. km3. Alat transportasi : ......................................................................................................4. Pekerjaan sebelumnya : ...................................................... jarak dari rumah ............. km5. Alat transportasi : ......................................................................................................6. Sumber-sumber pendapatan dan kecukupan terhadap kebutuhan : .........................................

Page 2: Format Pengkajian Keperawatan Gerontik

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

...................................................................................................................................................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 = ........... orang5. Derajat privasi : .........................................................................................................6. Tetangga terdekat : .........................................................................................................7. Alamat dan telepon : .........................................................................................................

E. Riwayat Rekreasi1. Hobby/minat : .............................................................................................2. Keanggotaan dalam organisasi : .............................................................................................3. Liburan/perjalanan : .............................................................................................

F. Sistem Pendukung1. Perawat/bidan/dokter/fisioterapi : .................................................. jaraknya .................. km2. Rumah sakit : .................................................. jaraknya .................. km3. Klinik : .................................................. jaraknya .................. km4. Pelayanan kesehatan di rumah : ..........................................................................................5. Makanan yang dihantarkan : ..........................................................................................6. Perawatan sehari-hari yang dilakukan keluarga : .....................................................................7. Lain-lain : ..........................................................................................

G. Deskripsi Kekhususan1. Kebiasaan ritual : .....................................................................................................................2. Yang lainnya : .....................................................................................................................

H. Status Kesehatan1. 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 :................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

Page 3: Format Pengkajian Keperawatan Gerontik

5. Obat-obatanNo. 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 ( ) DimensiaLain-lain : sebutkan ..................................................................................................................

I. Aktivitas Hidup Sehari-hari (ADL)1. Indeks Katz : A / B / C / D / E / F / G2. Oksigenasi : ...............................................................................................................3. Cairan & elektrolit : ...............................................................................................................4. Nutrisi : ...............................................................................................................5. Eliminasi : ...............................................................................................................6. Aktivitas : ...............................................................................................................7. Istirahat & tidur : ...............................................................................................................8. Personal hygiene : ...............................................................................................................9. Seksual : ...............................................................................................................10. Rekreasi : ...............................................................................................................11. Psikologis

a. Persepsi klien : .............................................................................................b. Konsep diri : .............................................................................................c. Emosi : .............................................................................................d. Adaptasi : .............................................................................................e. Mekanisme pertahanan diri : .............................................................................................

J. Tinjauan SistemKeadaan umum : ...............................................................................................................Tingkat kesadaran : Compos mentis / Apatis / Somnolen / Suporus / ComaSkala Koma Glasgow : Verbal = .......... Psikomotor = .......... Mata = .......... Total = ..........Tanda-tanda vital : Pulse = .......... Temp = .......... RR = .......... Tensi = .......... mmHg

1. Kepala................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

Page 4: Format Pengkajian Keperawatan Gerontik

2. Mata, telinga, hidung................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

3. Leher................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

4. Dada & punggung................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

5. Abdomen & pinggang................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

6. Ekstremitas atas dan bawah................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

7. Sistem immune................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

8. Genetalia................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

9. Sistem reproduksi................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

10. Sistem persyarafan................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

11. Sistem pengecapan................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

12. Sistem penciuman................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

13. Tactil respon................................................................................................................................................... ...................................................................................................................................................

Page 5: Format Pengkajian Keperawatan Gerontik

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

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

K. Status Kognitif / Afektif / Sosial1. Short Portable Mental Status Questionnaire (SPMSQ)

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

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

................................................................................................................................................... 2. Mini-Mental State Exam (MMSE)

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

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

................................................................................................................................................... 3. Inventaris Depresi Beck

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

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

................................................................................................................................................... 4. APGAR keluarga

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

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

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

L. Data Penunjang1. Laboratorium

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

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

................................................................................................................................................... 2. Radiologi

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

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

................................................................................................................................................... 3. ECG

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

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

................................................................................................................................................... 4. USG

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

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

................................................................................................................................................... 5. CT-Scan

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

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

................................................................................................................................................... 6. Obat-obatan

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

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

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

Page 6: Format Pengkajian Keperawatan Gerontik

II. ANALISA DATA

No.Data

(Sign / Symptom)Interprestasi

(Etiologi)Masalah

(Problem)

III. PRIORITAS MASALAH1. ......................................................................................................................................................2. ......................................................................................................................................................3. ......................................................................................................................................................4. ......................................................................................................................................................5. ......................................................................................................................................................6. ......................................................................................................................................................7. ......................................................................................................................................................

Page 7: Format Pengkajian Keperawatan Gerontik

PROSES KEPERAWATANDiagnosa Keperawatan Tujuan Intervensi Rasional

Page 8: Format Pengkajian Keperawatan Gerontik

PERKEMBANGAN KEPERAWATAN

No.Hari & Tanggal

PukulDiagnosa Keperawatan Perkembangan Keperawatan TTD

Page 9: Format Pengkajian Keperawatan Gerontik

INVENTARIS DEPRESI BECK

Untuk Mengetahui tingkat Depresi Lansia Dari Beck & Deck (1972)

Nama klien : ................................................................................ Tanggal : ................................Jenis kelamin : L / P Umur : ..... tahun TB / BB : ..... cm / ..... kgAgama : .................... Suku : .................... Gol. Darah : ....................Tahun pendidikan : .......... SD .......... SLTP .......... SLTA .......... PT Alamat : .................................................................................................................................

Skor Uraian

A. Kesedihan

3 Saya sangat sedih / tidak bhagia dimana saya tak dapat menghadapinya.

2 Saya galau / sedih sepanjang waktu dan saya tidak dapat keluar darinya.

1 Saya merasa sedih atau galau.

0 Saya tidak merasa sedih.

B. Pesimisme

3 Saya merasa bahwa masa depan adalah sia-sia dan sesuatu tidak dapat membaik.

2 Saya merasa tidak mempunyai apa-apa untuk memandang kedepan.

1 Saya merasa berkecil hati mengenai masa depan.

0 Saya tidak begitu pesimis atau kecil hati tentang masa depan.

C. Rasa Kegagalan

3 Saya merasa benar-benar gagal sebagai orang tua (suami/istri).

2 Bila melihat kehidupan kebelakang, semua yang dapat saya lihat hanya kegagalan.

1 Saya merasa telah gagal melebihi orang pada umumnya.

0 Saya tidak merasa gagal.

D. Ketidak Puasan

3 Saya tidak puas dengan segalanya

2 Saya tidak lagi mendapatkan kepuasan dari apapun.

1 Saya tidak menyukai cara yang saya gunakan.

0 Saya tidak merasa tidak puas

E. Rasa Bersalah

3 Saya merasa seolah-olah sangat buruk atau tak berharga.

2 Saya merasa sangat bersalah.

1 Saya merasa buruk/tak berharga sebagai bagian dari waktu yang baik

0 Saya tidak merasa kecewa dengan diri sendiri

F. Tidak Menyukai Diri Sendiri

3 Saya benci diri saya sendiri

2 Saya muak dengan diri saya sendiri

1 Saya tidak suka dengan diri saya sendiri

0 Saya tidak merasa kecewa dengan diri sendiri

G. Membahayakan Diri sendiri

3 Saya akan membunuh diri saya sendiri jika saya mempunyai kesempatan

2 Saya mempunyai rencana pasti tentang tujuan bunuh diri.

1 Saya merasa lebih baik mati.

0 Saya tidak mempunyai pikiran-pikiran mengenai membahayakan diri sendiri.

Page 10: Format Pengkajian Keperawatan Gerontik

H. Menarik Diri dari Sosial

3Saya telah kehilangan semua minat saya pada orang lain dan tidak perduli pada mereka semuanya.

2Saya telah kehilangan semua minat saya pada orang lain dan mempunyai sedikit perasaan pada mereka.

1 Saya kurang berminat pada orang lain dari pada sebelumnya

0 Saya tidak kehilangan minat pada orang lain

I. Keragu-raguan

3 Saya tidak dapat membuat keputusan sama sekali

2 Saya mempunyai banyak kesulitan dalam membuat keputusan

1 Saya berusaha mengambil keputusan

0 Saya membuat keputusan yan gbaik.

J. Perubahan Gambaran Diri

3 Saya merasa bahwa saya jelek atau tampak menjijikkan.

2Saya merasa bahwa ada perubahan-perubahan yang permanen dalam penampilan saya dan ini membuat saya tampak tua atau tak menarik

1 Saya khawatir bahwa saya tampak tua atau tak menarik

0 Saya tidak merasa bahwa saya tampak lebih buruk dari pada sebelumnya.

K. Kesulitan Kerja

3 Saya tidak melakukan pekerjaan sama sekali.

2 Saya telah mendorong diri saya sendiri dengan keras untuk melakukan sesuatu.

1 Saya memerlukan upaya tambahan untuk mulai melakukan sesuatu.

0 Saya dapat bekerja kira-kira sebaik sebelumnya.

L. Keletihan

3 Saya sangat lelah untuk melakukan sesuatu.

2 Saya merasa lelah untuk melakukan sesuatu.

1 Saya merasa lelah dari yang biasanya.

0 Saya tidak merasa lebih lelah dari biasanya

M. Anorekisa

3 Saya tidak lagi mempunyai nafsu makan sama sekali.

2 Napsu makan saya sangat memburuk sekarang.

1 Napsu makan saya tidak sebaik sebelumnya.

0 Napsu makan saya tidak buruk dari biasanya.

Penilaian

0 - 4 Depresi tidak ada atau minimal.

5 -7 Depresi ringan.

8 - 15 Depresi sedang.

16 + Depresi berat.

Dari Beck AT, Beck RW : screening depressed patients in family practice (1972)

Page 11: Format Pengkajian Keperawatan Gerontik

MINI – MENTAL STATE EXAM (MMSE)

Menguji Aspek-Aspek Kognitif Dari Fungsi Mental

NilaiPasien Pertanyaan

Maksimum

Orientasi    

5   (Tahun) (Musim) (Tanggal) (Hari) (Bulan apa sekarang) ?

5   Dimana kita : (negara bagian) (wilayah) (kota) (rumah sakit) (lantai)

Registrasi  

Nama 3 objek : 1 detik untuk mengatakan masing-masing. Kemudian

tanyakan klien ketiga objek setelah anda telah mengatakannya. Beri 1 poin

untuk setiap jawaban yang benar. Kemudian ulangi sampai ia mempelajarii

ketiganya. Jumlahkan percobaan dan catat.

  Percobaan :

Perhatian dan kalkulasi

5  Seri 7's. 1 poin untuk setiap kebenaran.

  Berhenti setelah 5 jawaban. Bergantian eja "kata" ke belakang.

Mengingat  

3  Minta untuk mengulang ketiga objek diatas.

  Berikan 1 poin untuk setiap kebenaran.

Bahasa  

9  Nama pensil dan melihat (2 poin)

  Mengulang hal berikut : "tak ada jika, dan, atau tetapi" (1 poin)

    Nilai total

Kaji Tingkat Kesadaran Sepanjang Kontinum :

Compos mentis Apatis Somnolen Soporus Coma

Keterangan :

Nilai maksimal 30, nilai 21 atau kurang biasanya indikasi adanya kerusakan kognitif yang memerlukan

penyelidikan lanjut.

Page 12: Format Pengkajian Keperawatan Gerontik

APGAR KELUARGA DENGAN LANSIA

Suatu Alat Skrining Singkat Yang Dapat Digunakan Untuk Mengkaji Fungsi Sosial Lansia

Nama klien : ................................................................................ Tanggal : ................................Jenis kelamin : L / P Umur : ..... tahun TB / BB : ..... cm / ..... kgAgama : .................... Suku : .................... Gol. Darah : ....................Tahun pendidikan : .......... SD .......... SLTP .......... SLTA .......... PT Alamat : .................................................................................................................................

No. Uraian Fungsi Skor

1Saya puas bahwa saya dapat kembali pada keluarga (teman-teman) saya untuk membantu pada waktu sesuatu menyusahkan saya.

Adaption  

2Saya puas dengan cara keluarga (teman-teman) saya membicarakan sesuatu dengan saya dan mengungkapkan masalah dengan saya.

Partnership  

3Saya puas bahwa keluarga (teman-teman) saya menerima dan mendukung keinginan saya untuk melakukan aktivitas atau arah baru.

Growth  

4Saya puas dengan cara keluarga (teman-teman) saya mengekspresikan afek dan berespons terhadap emosi-emosi saya, seperti marah, sedih atau mencintai.

Affection  

5Saya puas dengan cara teman-teman saya dan saya menyediakan watu bersama-sama.

Resolve  

       

  Penilaian :    

  Pertanyaan-pertanyaan yang dijawab;  

  1. Selalu : skor 2  

  2. Kadang-kadang : skor 1  

  3. Hampir tidak pernah : skor 0    

Page 13: Format Pengkajian Keperawatan Gerontik

INDEKS KATZ

Indeks Kemandirian Pada Aktivitas Kehidupan Sehari-hari

Nama klien : ................................................................................ Tanggal : ................................Jenis kelamin : L / P Umur : ..... tahun TB / BB : ..... cm / ..... kgAgama : .................... Suku : .................... Gol. Darah : ....................Tahun pendidikan : .......... SD .......... SLTP .......... SLTA .......... PT Alamat : .................................................................................................................................

Skor Kriteria

AKemandirian dalam hal makan, kontinen, berpindah, ke kamar kecil, berpakaian dan mandi.

B Kemandirian dalam semua aktivitas hidup sehari-hari, kecuali satu dari fungsi tersebut.

CKemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi dan satu fungsi tambahan.

DKemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi, berpakaian dan satu fungsi tambahan.

EKemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi, berpakaian, ke kamar kecil dan satu fungsi tambahan.

FKemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi, berpakaian, ke kamar kecil, berpindah dan satu fungsi tambahan.

G Ketergantungan pada keenam fungsi tersebut.

Lain-lainTergantung pada sedikitnya dua fungsi, tetapi tidak dapat diklasifikasikan sebagai, C, D, E atau F.

Page 14: Format Pengkajian Keperawatan Gerontik

SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ)

Penilaian Ini Untuk Mengetahui Fungsi Intelektual Lansia

Nama klien : ................................................................................ Tanggal : ................................Jenis kelamin : L / P Umur : ..... tahun TB / BB : ..... cm / ..... kgAgama : .................... Suku : .................... Gol. Darah : ....................Tahun pendidikan : .......... SD .......... SLTP .......... SLTA .......... PT Alamat : .................................................................................................................................Pewawancara : .................................................................................................................................

SkorNo. Pertanyaan Jawaban

+ -

    1 Tanggal berapa hari ini? Hari Tanggal Tahun

    2 Hari apa sekarang ini?  

    3 Apa nama tempat ini?  

    4Berapa nomor telepon anda?Dimana alamat anda?(Tanyakan bila tidak memiliki telepon)

 

    5 Berapa umur anda?  

    6 Kapan anda lahir?  

    7 Siapa presiden Indonesia sekarang?  

    8 Siapa presiden sebelumnya?  

    9 Siapa nama kecil Ibu anda?  

    10Kurangi 3 dari 20 dan tetap pengurangan 3 dari setiap angka baru, semua secara menurun?

 

       Jumlah kesalahan total  

Keterangan:

1. Kesalahan 0 – 2 Fungsi intelektual utuh

2. Kesalahan 3 – 4 Kerusakan intelektual ringan

3. Kesalahan 5 – 7 Kerusakan intelektual sedang

4. Kesalahan 8 – 10 Kerusakan intelektual berat

Bisa dimaklumi bila > 1 kesalahan bila subyek hanya berpendidikan sekolah dasar.

Bisa dimaklumi bila < 1 kesalahan bila subyek mempunyai pendidikan di atas sekolah menengah atas.

Bisa dimaklumi bila > 1 kesalahan untuk subyek kulit hitam, dengan menggunakan kriteria pendidikan

yang sama.

Page 15: Format Pengkajian Keperawatan Gerontik

STIKES HANG TUAH SURABAYA

PROGRAM STUDI ILMU KEPERAWATAN

Departemen Keperawatan Gerontik

Jl. Gadung No. 1 Surabaya telp 031.8411721

Format Pengkajian Kelompok Usia Lanjut

Panti Wreda

A. IDENTITAS PANTI1. Nama Panti : ..............................................................................................................................2. Alamat Panti : ..............................................................................................................................3. Type Panti : ..............................................................................................................................

B. LATAR BELAKANG PENDIRIAN PANTI...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

C. VISI, MISI DAN MOTTO PANTI1. Visi :

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

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

.........................................................................................................................................................2. Misi :

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

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

.........................................................................................................................................................3. Motto :

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

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

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

D. TUJUAN PANTI1. Tujuan Umum :

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

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

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

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

.........................................................................................................................................................2. Tujuan Khusus:

a. ...................................................................................................................................................b. ...................................................................................................................................................c. ...................................................................................................................................................d. ...................................................................................................................................................e. ...................................................................................................................................................f. ...................................................................................................................................................g. ...................................................................................................................................................h. ...................................................................................................................................................i. ...................................................................................................................................................j. ...................................................................................................................................................

Page 16: Format Pengkajian Keperawatan Gerontik

E. STRUKTUR ORGANISASI

F. KAPASITAS PANTIJumlah Usia Lanjut berdasarkan Kriteria WHO1. Usia 55-59 : .......... jiwa2. Usia 60-64 : .......... jiwa3. Usia 65 keatas : .......... jiwa

G. SARANA DAN PRA-SARANA PANTI1. Bangunan Perumahan2. Sarana Air Bersih3. Jamban Keluarga4. Sarana Pembuangan Air Limbah5. Sarana Ibadah

H. KEGIATAN DALAM PANTI1. Jadwal kegiatan usia lanjut

a. Dalam per hari : ...............................................................................................................b. Dalam per minggu : ...............................................................................................................c. Dalam per bulan : ...............................................................................................................

2. Jadwal kegiatan pengurus pantia. Dalam per hari : ...............................................................................................................b. Dalam per minggu : ...............................................................................................................c. Dalam per bulan : ...............................................................................................................d. Dalam per tahun : ...............................................................................................................

I. HUBUNGAN LINTAS PROGRAM DAN SEKTORAL1. Lintas program : ...........................................................................................................................2. Lintas sektoral : ...........................................................................................................................

J. DISTRIBUSI PENDANAAN1. Swadana : .................................................................................................................................2. Donatur : .................................................................................................................................3. Dinas sosial : .................................................................................................................................

K. DATA KESEHATAN PER TAHUN1. Jumlah kematian :2. Jumlah kesakitan :3. Urutan (5) lima penyakit terbanyak pada usia lanjut :

a. ...................................................................................................................................................b. ...................................................................................................................................................c. ...................................................................................................................................................d. ...................................................................................................................................................e. ...................................................................................................................................................

Page 17: Format Pengkajian Keperawatan Gerontik

4. Tempat pelayanan kesehatan & keperawatana. Rumah sakit : .....................................................................................................................b. Pukesmas : .....................................................................................................................c. Dokter praktik : .....................................................................................................................d. Perawat/badan : .....................................................................................................................e. Posyandu : .....................................................................................................................f. Lain-lain : .....................................................................................................................

Page 18: Format Pengkajian Keperawatan Gerontik

NoDiagnosa

keperawatanTujuan/

IntervensiIntervensi Implementasi Evaluasi

Page 19: Format Pengkajian Keperawatan Gerontik