ASUHAN KEPERAWATAN GERONTIK

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ASUHAN KEPERAWATAN GERONTIK PADA NY. D DENGAN REUMATIK DI SUB UNIT PERLINDUNGAN SOSIAL TRESNA WERDHA SUKMA RAHARJA A. PENGKAJIAN 1. Identitas Klien Nama : Ny. D Umur : 80 tahun Jenis Kelamin : Perempuan Suku : Betawi Agama : Islam Pendidikan : SPR Status Perkawinan : Menikah (Janda) Tanggal Pengkajian : 06 Mei 2010 Alamat : Depok 2. Status Kesehatan Saat ini Ny. D mengatakan kaki kanannya merasa pegal, linu dan kesemutan. Hal itu dirasakan oleh Ny. D sejak 6 bulan terakhir. Rasa kesemutan dan linu bertambah ketika Ny. D selesai mencuci pakaian atau mencuci piring, serta terlalu lama melakukan aktivitas. 3. Riwayat Kesehatan Dahulu Ny. D mengatakan tidak memiliki riwayat penyakit apapun. 4. Riwayat Kesehatan Keluarga

Ny. D mengatakan suaminya tidak memilki riwayat penyakit apapun. 5. Pemeriksaan Tanda-tanda Vital Tekanan darah : 130/80 mmHg Nadi : 86 kali/menit Suhu : 36.0 oC Respirasi : 20 kali/menit Berat badan : 50kg 6. Pemeriksaan Fisik 1. Keadaan umum Keadaan Ny. D tampak sehat dan tampak memegangi kaki kanannya. 2. Kepala, wajah, mata, leher Bentuk kepala tampak bulat, tidak ada lesi dan benjolan, rambut tampak beruban, rambut lurus Sklera tidak ikterik, konjungtiva tidak anemis, pupil isokhor, mata kanan tampak sering berair, pergerakan bola mata simetris Tidak teraba ada pembesaran kelenjar getah bening Hidung tampak simetris, tidak tampak ada cairan berlebih 3. Sistem pernapasan Bentuk thorax simetris, tidak tampak ada retraksi intercostal, vocal premitus merata di semua lapang paru, perkusi terdengar resonance, auskultasi terdengar

vesikular 4. Sistem kardiovaskuler Perkusi jantung terdengar pekak, irama jantung terdengar regular. 5. Sistem Gastrointestinal Tampak tidak ada lesi dan tidak ada benjolan, bising usus terdengar 8x/menit, perkusi terdengar tymphani. 6. Sistem urinaria Ny. D BAK 5-6 kali sehari, tidak sakit saat BAK dan lancar. 7. Sistem muskulosceletal Kedua kaki dan tangan Ny. D tampak sejajar dan sama besar dan panjang, tampak adanya scoliosis. Kemampuan mengubah posisi baik, pergerakan kedua tangan dan kaik baik, kekuatan otot baik, tetapi kaki kanan sering merasa linu dan kesemutan. 8. Sistem syaraf pusat Tidak ada cedera kepala, tidak ada peningkatan TIK, tidak memiliki riwayat kejang 9. Sistem endokrin Ny. D mengatakan tidak mempunyai penyakit gula dan gondok. 10. Sistem reproduksi

Ny. D mengatakan pernah menikah 2 kali dan dikaruniai 2 anak tetapi sudah meninggal sejak kecil. 11. Sistem integument Kulit tampak keriput, warna kulit sawo matang, tampak ada lesi, elastisitas kulit berkuang. 12. Sistem hemopoetik 7. Pengkajian Psikososial & Spiritual Psikososial Ny. D mengatakan dapat bersosialisasi dengan penghuni panti yang lainnya. Status emosi Ny. D stabil dan kooperatif saat diajak bicara, sikap klien terhadap penghuni panti lainnya baik. 2. Spiritual Ny. D beragama Islam, dan mengatakan selalu menjalankan ibadah sholat lima waktu. Selain itu juga mengikuti pengajian minggguan yang diadakan di panti. 8. Pengkajian Fungsional Klien Katz indexNo. 1. 2. 3. 4. 5. 6. Kegiatan Mandi Berpakaian Ke Kamar Kecil Berpindah Tempat BAK/BAB Makan/Minum Mandiri a a a a a a

Bantuan Sebagia

Ny. D dapat beraktivitas secara mandiri tanpa pengawasan, pengarahan, atau bantuan aktif dari orang lain. 2. Barthel indexNo. 1. 2. 3. 4 5. 6. 7. 8. 9. 10. Kegiatan Makan/Minum Berpindah dari kursi roda ke tempat tidur/sebaliknya Kebersihan diri (cuci muka, gosok gigi, menyisir rambut) Keluara masuk kamar mandi (menyeka tubuh, menyiram, mencuci baju) Mandi Jalan-jalan di permukaan datar Naik turun tangga Memakai baju Kontrol BAK Kontrol BAB 0 0 0 0 0 0 0 0 0 0 0

Dengan Bantuan

Jumlah

Kesimpulan: Jumlah skor 100 = mandiri 9. Pengkajian Status Mental Short Portable Mental Status Questioner (SPSMQ)Benar a a a a a a Salah No. 1. 2. 3. 4. 5. 6. Pertanyaan Tanggal berapa hari ini? Hari apa sekarang? Apa nama tempat ini? Dimana alamat anda? Berapa umur anda? Kapan anda lahir?

a a a a 10

7. 8. 9. 10. Jumlah

Siapa presiden Indonesia sekarang? Siapa presiden Indonesia sebelumnya? Siapa nama ibu anda?

Kurangi 3 dari 20 & tetap pengurangan 3 dari setiap angka bar

Total Skor: Salah: 4 Benar: 6 Hasil: Salah 4-5 : kerusakan intelektual ringan 10. Pengkajian Aspek Kognitif Dari Fungsi MentalNo. 1. Aspek Kognitif Orientasi Nilai Mhs 5 Nilai Klien 1 Kriteria

Menyebutkan de

2. Orientasi 5 5

Tahun Musim Tangg Hari Bulan

Menyebutkan de

Negara Propin Kota Panti3. Registrasi 5 5

Pemeriksa meng kemudian klien m

Objek Objek

4. Perhatian & Kalkulasi 5

Objek 100 93 86 79 72

Minta klien untu dikurangi 7 samp

5. Mengingat 5

Minta klien untu objek pada no.2

Objek Objek Objek6. Bahasa 9 Tunjukkan pada namanya!

Objek Objek Minta klie kata beri Tak ad Dan a Tetapi (bila ben Minta klie perintah Ambil Lipat d Taruh

Perintahk hal berik perintah Tutup Perintahk satu kali gambar: Tulis s MenyaTotal Nilai 23

Interpretasi hasil : Nilai 8-22 fungsi mental ringan ANALISA DATANo. 1. Data Senjang DS:

= kerusakan aspek

Kemungkinan Penyebab Proses menua

Ny T mengatakan sudah dua tahun merasa kesemutan dan linu pada kakinya Ny T mengatakan rasa kesemutan dan linu bertambah jika terkena dingin dan berkurang setelah minum obat. DO: TD :130/90 mmHg Nadi : 80 x/menit Suhu : 36 C Respirasi : 24 x/menit

Perubahan hormonal Permukaan tulang dan sendi tidak lagi licin Tulang mengalami gesek Nyeri

Ny T tampak memegangi kakinya2. DS: Proses menua

Ny T mengatakan tidak mengerti tentang Penurunan daya ingat penyakit rematik, makanan pantangan dan Kurang terpapar informa cara pengobatan untuk rematik Kurang pengetahuan DO: tentang rematik Ny T tampak bertanya tentang rematik, makanan pantangan dan cara pengobatan rematik C. DIAGNOSA KEPERAWATAN Nyeri akut akibat proses inflamasi pada daerah kaki b.d kesemutan dan rasa ngilu pada persendian Kurang pengetahuan tentang rematik berhubungan dengan keterbatasan kognitif D. RENCANA INTERVENSI KEPERAWATANTgl No. Dx Diagnosa Keperawatan Rencana Tujuan 06 Mei 1. 2010 Nyeri akut akibat proses Tupan: inflamasi pada daerah kaki b.d kesemutan dan rasa ngilu padaNyeri persendian Kriteria Hasil Setelah dilakukan intervensi hasil yang diharapkan: Intervensi

anjurkan kl hilang mandi ai dan proses Ny D melaporkan kompres DS: rasa kesemutan yang sak inflamasi Ny D mengatakan kompres dapat diatasi dan ngilu sudah dua tahun berkurang berikan ma Tupen :

merasa kesemutan Rasa Ny D dapat lembut dan linu pada kesemutan beraktifitas ajarkan tekn kakinya tanpa rasa ngilu dan distr dan ngilu Ny D mengatakan dan kesemutan. kolaborasi berkurang/ rasa kesemutan dan kaji keluhan yang sesuai in linu bertambah jika teratasi. dirasakan klien, diberikan terkena dingin dan catat faktor berkurang setelah yang minum obat mempercepat dan tanda-tanda DO: rasa sakit non TD :130/80 mmHg verbal. Nadi : 86 x/menit Suhu : 36,0 C Respirasi : 20 x/menit Ny D tampak memegangi kakinya

Tgl

No. Dx

Diagnosa Keperawatan

Rencana Tujuan Kriteria Hasil

In

06 Mei 2. 2010

Kurang pengetahuan tentang rematik b.d keterbatasan kognitif

Tupan : Pengetahuan Ny D tentang rematik adekuat

DS: Ny D

p Ny D mengatakan Tupen : paham mengenai Ber Pengetahuan k penyakitnya Ny D

Setelah dilakukan intervensi Kaj diharapkan:

mengatakan bertambah tidak mengerti tentang penyakit rematik, makanan pantangan dan cara pengobatan untuk rematik DO: Ny D tampak bertanya tentang rematik, makanan pantangan dan cara pengobatan tradisional untuk rematik E. IMPLEMENTASI DAN EVALUASITanggal 06 Mei 2010 No. 1 Implementasi Evaluasi

c m Eva p Me m in

Membina hubungan saling percaya S : Ny D mengatakan dengan klien tahun merasa k

Mengkaji keluhan yang dirasakan linu pada kakin klien, catat faktor yang Ny D mengatakan mempercepat dan tanda-tanda rasa kesemutan dan sakit non verbal. jika terkena din Menganjurkan klien untuk mandi air berkurang sete hangat, kompres sendi- sendi yang O : sakit dengan kompres hangat TD :130/80 mmH Mengajarkan teknik relaksasi dan Nadi : 86 x/menit distraksi Suhu : 36,0 C Berkolaborasi pemberian obat sesuai Respirasi : 20 x/m indikasi yang diberikan Ny D tampak me kakinya s Ny D tampak me teknik relaksas nafas dalam A: Masalah ter P: Lanjutkan in Kaji pengeahuan penyakit remat Berikan penkes te rematik Like this: Like Be the first to like this post.

1 Response to "ASUHAN

KEPERAWATAN GERONTIK DENGAN REUMATIK"1 | Asuhan Keperawatan NANDAJune 10, 2012 at 7:16 pm

artikel yang bagus kalau bisa ditambahkan diagnosa NANDA ya terima kasih. Reply

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