PRAKTEK PROFESI KEPERAWATAN

GERONTIK
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PENGKAJIAN INDIVIDU

NAMA PANTI : ____________________________________

ALAMAT PANTI : ____________________________________
TANGGAL MASUK : ____________________________________
NO. REGISTER : ____________________________________

I. IDENTITAS
A. Nama Inisial : ____________________________________
B. Jenis Kelamin : ____________________________________
C. Umur : ____________________________________
D. Agama : ____________________________________
E. Status Perkawinan : ____________________________________
F. Pendidikan Terakhir : ____________________________________
G. Pekerjaan : ____________________________________
H. Alamat Rumah : ____________________________________

II. ALASAN KUNJUNGAN KE PANTI

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III. RIWAYAT KESEHATAN
a. Masalah kesehatan yang pernah dialami dan dirasakan saat ini

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b. Masalah kesehatan keluarga/keturunan
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IV. KEBIASAAN SEHARI-HARI
A. BIOLOGIS
1. Pola Makan

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GERONTIK
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2. Pola Minum
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3. Pola Tidur
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4. Pola Eliminasi (BAB/BAK)
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5. Aktivitas Sehari-hari
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6. Rekreasi
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GERONTIK
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B. PSIKOLOGIS
1. Keadaan Emosi
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C. SOSIAL
1. Dukungan Keluarga
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2. Hubungan Antar-Keluarga
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3. Hubungan dengan Orang Lain
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D. SPIRITUAL/KULTURAL
1. Pelaksanaan Ibadah
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GERONTIK
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2. Keyakinan tentang Kesehatan
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V. PEMERIKSAAN FISIK
a. Tanda Vital
Keadaan umum : ____________________________________
Kesadaran : ____________________________________
Suhu : ____________________________________
Nadi : ____________________________________
Tekanan darah : ____________________________________
Pernapasan : ____________________________________
Tinggi badan : ____________________________________
Berat badan : ____________________________________
b. Kebersihan Perorang
1. Kepala
Rambut : ________________________________________________
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Mata : ________________________________________________
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Hidung : ________________________________________________
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Mulut : ________________________________________________
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Telinga : ________________________________________________
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2. Leher : ________________________________________________
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3. Dada/Thorax
Dada : ________________________________________________
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GERONTIK
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Paru-Paru : ________________________________________________
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Jantung : ________________________________________________
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4. Abdomen : ________________________________________________
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5. Muskuloskeletal : ________________________________________________
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6. Lain-lain : ________________________________________________
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7. Keadaan Lingkungan
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VI. INFORMASI PENUNJANG
Diagnosa Medis
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Laboratorium
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Terapi Medis
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 PRAKTEK PROFESI KEPERAWATAN
GERONTIK
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Lasucy Mentari S.Kep

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