PRAKTEK PROFESI KEPERAWATAN GERONTIK FAKULTAS KEPERAWATAN UNAND 2017 ________________________________________________________________________ LAPORAN KASUS ASUHAN KEPERAWATAN GERONTIK Nama Panti : _______________________________________ Alamat Panti : _______________________________________ Tanggal Masuk : _______________________________________ No. Register I. : _______________________________________ IDENTITAS a. Nama : _______________________________________ b. Jenis Kelamin : _______________________________________ c. Umur : _______________________________________ d. Agama : _______________________________________ e. Status Perkawinan : _______________________________________ f. Pendidikan Terakhir : _______________________________________ g. Pekerjaan : _______________________________________ h. Alamat rumah : _______________________________________ II. ALASAN KUNJUNGAN KE PANTI ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ III. RIWAYAT KESEHATAN a. Masalah kesehatan yang pernah dialami dan dirasakan saat ini: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ IRENE PRADITA, S.KEP 1841312068 PRAKTEK PROFESI KEPERAWATAN GERONTIK FAKULTAS KEPERAWATAN UNAND 2017 ________________________________________________________________________ b. Masalah kesehatan keluarga/keturunan ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ IV. KEBIASAAN SEHARI-HARI a. Biologis Pola Makan ___________________________________________________________ ___________________________________________________________ Pola Minum ___________________________________________________________ ___________________________________________________________ Pola Tidur ___________________________________________________________ ___________________________________________________________ Pola Eliminasi (BAK & BAB) ___________________________________________________________ ___________________________________________________________ Aktivitas Sehari-hari ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Rekreasi ___________________________________________________________ ___________________________________________________________ IRENE PRADITA, S.KEP 1841312068 PRAKTEK PROFESI KEPERAWATAN GERONTIK FAKULTAS KEPERAWATAN UNAND 2017 ________________________________________________________________________ b. Psikologis Keadaan Emosi ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ c. Sosial Dukungan Keluarga ___________________________________________________________ ___________________________________________________________ Hubungan Antar Keluarga ___________________________________________________________ ___________________________________________________________ Hubungan dengan Orang Lain ___________________________________________________________ ___________________________________________________________ d. Spiritual/kultural Pelaksanaan Ibadah ___________________________________________________________ ___________________________________________________________ Keyakinan Tentang Kesehatan ___________________________________________________________ ___________________________________________________________ e. Pemeriksaan fisik Tanda Vital 1) Keadaan Umum :_____________________________________ 2) Kesadaran :_____________________________________ IRENE PRADITA, S.KEP 1841312068 PRAKTEK PROFESI KEPERAWATAN GERONTIK FAKULTAS KEPERAWATAN UNAND 2017 ________________________________________________________________________ 3) Suhu : 4) Nadi : o C x/i 5) Tekanan Darah : mmHg 6) Pernafasan : x/i 7) Tinggi Badan : cm 8) Berat Badan : kg Kebersihan Perorangan 1) Kepala - Rambut : _________________________________________ _________________________________________ - Mata : _________________________________________ _________________________________________ - Hidung : _________________________________________ - Mulut : _________________________________________ : _________________________________________ - Telinga : _________________________________________ : _________________________________________ 2) Leher ________________________________________________________ ________________________________________________________ 3) Dada/Thorax - - Paru Insp : _________________________________________ Palp : _________________________________________ Perk : _________________________________________ Ausk : _________________________________________ Jantung Insp : _________________________________________ Palp : _________________________________________ Perk : _________________________________________ Ausk : _________________________________________ IRENE PRADITA, S.KEP 1841312068 PRAKTEK PROFESI KEPERAWATAN GERONTIK FAKULTAS KEPERAWATAN UNAND 2017 ________________________________________________________________________ 4) Abdomen Insp : _________________________________________ Palp : _________________________________________ Perk : _________________________________________ Ausk : _________________________________________ 5) Muskuloskeletal Kekuatan Otot : ________________________________________________________ ________________________________________________________ 6) Keadaan Lingkungan ________________________________________________________ ________________________________________________________ V. INFORMASI PENUNJANG Diagnosa Medis ______________________________________________________________ ______________________________________________________________ Laboratorium ______________________________________________________________ ______________________________________________________________ Terapi Medis Obat-obatan Obat Dosis Frekuensi IRENE PRADITA, S.KEP 1841312068 PRAKTEK PROFESI KEPERAWATAN GERONTIK FAKULTAS KEPERAWATAN UNAND 2017 ________________________________________________________________________ ANALISA DATA No Data Masalah Keperawatan IRENE PRADITA, S.KEP 1841312068 PRAKTEK PROFESI KEPERAWATAN GERONTIK FAKULTAS KEPERAWATAN UNAND 2017 ________________________________________________________________________ NANDA, NOC, NIC No Diagnosa Keperawatan NOC NIC IRENE PRADITA, S.KEP 1841312068 PRAKTEK PROFESI KEPERAWATAN GERONTIK FAKULTAS KEPERAWATAN UNAND 2017 ________________________________________________________________________ NANDA, NOC, NIC No Diagnosa Keperawatan NOC NIC IRENE PRADITA, S.KEP 1841312068 PRAKTEK PROFESI KEPERAWATAN GERONTIK FAKULTAS KEPERAWATAN UNAND 2017 ________________________________________________________________________ NANDA, NOC, NIC No Diagnosa Keperawatan NOC NIC IRENE PRADITA, S.KEP 1841312068 PRAKTEK PROFESI KEPERAWATAN GERONTIK FAKULTAS KEPERAWATAN UNAND 2017 ________________________________________________________________________ IRENE PRADITA, S.KEP 1841312068