ASUHAN KEPERAWATAN PADA LANSIA DI KELUARGA

A. PENGKAJIAN

Hari/ Tanggal : ......................................................................................................

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I. Identitas Pasien

a. Nama kepala keluarga : ..........................................................................

b. Umur kepala keluarga : ..........................................................................

c. Alamat : ..........................................................................

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d. Pendidikan kepala keluarga : ..........................................................................

e. Pekerjaan : ..........................................................................

f. Komposisi keluarga

Jenis Hubungan
No. Nama Usia Pendidikan Pekerjaan Ket.
Kelamin dengan KK

Genogram :
 g. Tipe keluarga : ..........................................................................

h. Agama : ..........................................................................

i. Suku Bangsa : ..........................................................................

j. Status sosial ekonomi keluarga : ....................................................................

k. Aktivitas rekreasi keluarga : ..........................................................................

II. Riwayat dan Tahapan Perkembangan Keluarga

1. Tahap perkembangan keluarga saat ini

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2. Tahap perkembangan keluarga yang belum terpenuhi

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 3. Riwayat keluarga inti

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4. Riwayat keluarga sebelumnya

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III. Lingkungan

1. Krakteristik rumah

→ Denah rumah
 2. Karakteristik tetangga dan komunitas
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3. Mobilitas grafis keluarga

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4. Perkumpulan keluarga dan interaksi komunitas

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5. Sistem pendukung keluarga

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IV. Struktur keluarga

1. Pola Komunikasi keluarga

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 2. Struktur kekuatan keluarga
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3. Struktur Peran
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4. Nilai atau norma keluarga

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V. Fungsi Keluarga

1. Fungsi Afektif

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2. Fungsi sosialisasi

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 3. Fungsi perawatan

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VI. Stres dan Koping Keluarga

1. Stresor yang dimiliki

a. Stresor jangka pendek

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b. Stresor jangka panjang

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2. Kemampuan keluarga berespon terhadap situasi/stresor

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3. Strategi koping yang digunakan

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 4. Strategi adaptasi keluarga

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5. Harapan keluarga

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VII. Pemeriksaan Fisik

1. Tabel pemeriksaan fisik

Pemeriksaan Nama pasien (inisial)

Kepala

Leher

Telinga

Mata

Mulut dan hidung

Dada dan paru-paru

Abdomen

Reproduksi

Eliminasi

Sistem Integumen

Sistem
muskuloskeletal

BB dan TB

Tanda- tanda vital

 Pemeriksaan lain

Ekstremitas

Keluhan Utama

2. Pola aktivitas dan latihan (khusus lansia)

Kemampuan Perawatan Diri 0 1 2 3 4

Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah/berjalan
Ambulasi/ROM
Keterangan :
0 : mandiri, 1 : alat bantu, 2 : dibantu orang lain, 3 : dibantu orang lain dan
alat, 4 :bergantung total.
3. Pola tidur dan istirahat
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4. Pola persepsi diri(khusus lansia)

a. Gambaran diri

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b. Ideal diri

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c. Harga diri
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d. Identitas diri
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e. Peran diri
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5. Masalah psikososial (khusus lansia)

a. Dukungan keluarga dan kelompok

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b. Hubungan dengan lingkungan

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c. Keadaan pekerjaan, perumahan, ekonomi

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d. Pelayanan kesehatan dan harapan

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e. Mekanisme koping dan adaptasi stress

1). Koping adaptif

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2). Koping maladaptive

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6. Status Kognitif/ Afektif/ Sosial

a. Short Portable Mental Status Questionnaire (SPMSQ)

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b. Mini-Mental State Exam (MMSE)

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c. Inventaris Depresi Beck

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d. Resiko Jatuh (Keseimbangan)

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e. Indeks Katz
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f. Indeks Barthel
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g. Skor APGAR
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B. ANALISA DATA
No Data Masalah Keperawatan
No Data Masalah Keperawatan
 SKORING

Kriteria Bobot Total Pembenaran

Sifat masalah:
Defisit kesehatan (3)
Ancaman kesehatan (2)
Faktor risiko (1)
Kemungkinan diubah:
Mudah (2)
Sebagian (1)
Tidak dapat (0)
Kemungkinan dicegah:
Tinggi (3)
Cukup (2)
Rendah (1)

Menonjolnya masalah: .
Membutuhkan perhatian
segera (2)
Tidak membutuhkan
perhatian segera (1)
Tidak dirasakan sebagai
masalah atau kondisi
yang membutuhkan
perubahan (0)
Total
C. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS
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 D. PERENCANAAN
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 E. PELAKSANAAN DAN EVALUASI
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