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ASUHAN KEPERAWATAN LANSIA
DENGAN HIPERTENSI
Disusun Untuk Memenuhi Tugas Program Pendidikan Profesi
Pada Stase Keperawatan Gerontik
Disusun oleh :
TIA NURCAHYANI,S.KepNIM I41B110016
PROGRAM PROFESI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS LAMBUNG MANGKURAT
BANJARBARU
2015
ASUHAN KEPERAWATAN GERONTIK
PADA ............................................................................
Nama Mahasiswa : Tia Nurcahyani, S.Kep
Tempat Praktek : ..............................................................................................
Tanggal Praktek : ..............................................................................................
Tanggal pengkajian : ..............................................................................................
I. Identitas diri Klien
Nama : ..........................................................................................Umur : ..........................................................................................Jenis Kelamin : ..........................................................................................Alamat : ..........................................................................................Status Perkawinan : ..........................................................................................Agama : ..........................................................................................Suku : ..........................................................................................Pendidikan : ..........................................................................................Pekerjaan : ..........................................................................................Lama Bekerja : ..........................................................................................Sumber informasi : ..........................................................................................Tanggal masuk panti : ..........................................................................................Alasan di bawa ke panti : ..........................................................................................
II. Struktur Keluarga
No
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Nama Umur JK Hub dengan klien Pekerjaan Ket
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Genogram
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III. Riwayat Penyakit Keluarga
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....................................................................................................................................IV. Riwayat Penyakit
1. Keluhan utama saat ini : ………………………………………………………..........................................................................................................................................................................................................................................................
2. Apa yang dipikirkan saat ini : ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Siapa yang paling dipikirkan saat ini: ..........................................................................................................................................................................................................................................................................................................................
4. Riwayat penyakit dahulu : ……………………………………………………....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
V. Pengkajian
1. Persepsi dan pemeliharaan kesehatan : ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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...............................................................................................................................2. Pola Nutrisi : ........................................................................................................
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3. Pola eliminasi : ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4. Pola aktivitas dan latihan:
Kemampuan merawat 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 : tergantung total
5. Pola tidur dan istirahat : ………………………………………………………….....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
6. Pola perceptual
Penglihatan : .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Pendengaran : .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Pengecap : .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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...............................................................................................................................Sensasi : .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
7. Pola Persepsi diri : .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
8. Pola peran hubungan : ………………………………………………………….......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9. Pola managemen koping stress : ………………………………………………...
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...............................................................................................................................10. Sistem nilai dan keyakinan : …………………………………………………..
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VI. Pemeriksaan Fisik
1. Pemeriksaan Fisik
a. Tingkat kesadaran : ..............................................................................................b. TD : ................ mmHg Nadi : .............. x/menit RR : ............... x/menitc. Temperatur : ................... °C BB : .................. Kg TB : ............... cmd. Kepala : ...............................................................................................................
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...............................................................................................................................e. Leher : ...............................................................................................................
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...............................................................................................................................f. Thorax (bentuk dada, retraksi otot dada, turgor kulit ) : ......................................
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...............................................................................................................................g. Abdomen (Ascites, kembung, nyeri tekan) : ........................................................
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...............................................................................................................................h. Ekstrimitas (kekuatan otot) : ................................................................................
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2. Pemeriksaan panca indera
a. Penglihatan (mata)1) Bola mata : ................................................................................................. 2) Konjungtiva : .................................................................................................3) Sklera : .................................................................................................4) Reflek pupil : .................................................................................................5) Visus : .................................................................................................
b. Pendengaran (telinga)
1) Bentuk telinga: ..............................................................................................2) Nyeri tekan : ada / tidak ada3) Liang telinga : serumen ada / tidak ada4) Gangguan pendengaran : ada / tidak ada5) Menggunakan alat bantu dengar ( )
c. Pengecapan
1) Gigi geligi : bersih / tidak, gigi tinggal bagian atas depan ( )2) Lidah : bersih / tidak3) Sensasi rasa manis ( ), asin ( ), dan pahit ( )
d. Sensasi (kulit)
1) Sensasi nyeri ( ), Sensasi taktil ( ), Sensasi suhu ( )2) Turgor kulit : baik / buruk
e. Penciuman (Hidung)
1) Lubang hidung : simetris / tidak2) Septum nasi : lurus / tidak3) Konka : normal / tidak4) Secret : ada / tidak
VII. Analisa Data
Data Problem Etiologi
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Data Problem Etiologi
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VIII. Diagnosa Sesuai Prioritas
1. ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2. ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
IX. Rencana Keperawatan
DiagnosaKeperawatan
Rencana keperawatan
Tujuan Intervensi
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DiagnosaKeperawatan
Rencana keperawatan
Tujuan Intervensi
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X. Catatan Perkembangan
No. Dx
Hari/Tanggal/Jam Implementasi Evaluasi
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No. Dx
Hari/Tanggal/Jam Implementasi Evaluasi
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