ASUHAN KEPERAWATAN GERONTIK PADA LANSIA.................DENGAN................................................................................
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TANGGAL..........................................................................
Nama Mahasiswa :
NIM :
Tanggal Pengkajian :
Tanggal Praktek :
I. PENGKAJIAN / PENGUMPULAN DATAA. IDENTITAS/DATA BIOGRAFIS KLIEN1. Nama :2. Jenis Kelamin :3. Tempat Tanggal Lahir :4. Agama :5. Status Perkawinan :6. Pekerjaan :7. Pendidikan Terakhir :8. Alamat Rumah :9. Orang dekat yang dihubungi :10. Hubungan dengan Klien :B. KELUHAN UTAMA
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........................................................................................................................C. RIWAYAT KESEHATAN SAAT INI
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D. RIWAYAT KESEHATAN MASA LALU................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
E. GENOGRAM
F. RIWAYAT PENYAKIT KELUARGA.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
G. RIWAYAT PEKERJAAN........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
H. RIWAYAT LINGKUNGAN HIDUP................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
I. RIWAYAT REKREASI........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
J. SISTEM PENDUKUNG................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
K. SPIRITUAL/KULTURAL1. Pelaksanaan Ibadah
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.......................................................................................................................2. Keyakinan tentang kesehatan
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.......................................................................................................................L. PEMERIKSAAN FISIK
TINJAUAN SISTEM1. Keadaan Umum2. Tingkat Kesadaran : (Compos mentis/Apatis/Somnolen/Supor/Coma)3. Gaslow Coma Scale : E: M: V:4. Tanda-Tanda Vital
a. Suhu :b. Nadi :c. Tekanan darah :d. Pernafasan :
5. Tinggi Badan :6. Berat Badan :7. IMT :8. Sistem Kardiovaskuler
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........................................................................................................................9. Sistem Pernafasan
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10. Sistem Integumen........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
11. Sistem Perkemihan........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
12. Sistem Muskulosekletal........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
13. Sistem Endokrin........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
14. Sistem Imun........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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15. Sistem Gastrointestinal........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
16. Sistem Reproduksi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
17. Sistem Neurosensori........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
M. Pengkajian psikososial dan spiritual1. Psikososial
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2. Identifikasi masalah emosional........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Spiritual.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
N. ADL (Activity Daily Living)1. INDEKS KATZ
Skore KreteriaA Kemandirian dalam hal makan, kontinen (BAB atau BAK),
berpindah, ke kamar kecil, mandi dan berpakaianB Kemandirian dalam semua hal, kecuali satu dari fungsi tersebutC Kemandirian dalam semua hal, kecuali mandi dan satu fungsi
tambahanD Kemandirian dalam semua hal kecuali mandi, berpakaian, dan
satu fungsi tambahanE Kemandirian dalam semua hal, kecuali mandi, berpakaian, ke
kamar kecil, dan satu fungsi tambahanF Kemandirian dalam semua hal kecuali mandi, berpakaian, ke
kamar kecil, berpindah dan satu fungsi tambahanG Ketergantungan pada keenam fungsi tersebutLain-Lain
Tergantung pada sedikitnya dua fungsi, tetapi tidak dapat diklasifikasikan sebagai C, D, E, atau F
Keterangan :
Mandiri berarti tanpa pengawasan, pengarahan atau tanpa bantuan efektif dari orang lain, seseorang yang menolak untuk melakukan suatu fungsi dianggap tidak melakukan fungsi meskipun ia dianggap mampu
2. MODIFIKASI BARTHEL INDEKS
No Item yang di nilai
Skor Nilai
1 Makan (Feeding)
0 = Tidak mampu1 = Butuh bantuan memotong, mengoles mentega, dll2 = Mandiri
2 Mandi (Bathing)
0 = Tergantung dengan orang lain1 = Mandiri
3 Perawatan Diri (Grooming)
0 = Membutuhkan bantuan orang lain1 = Mandiri dalam perawatan muka, rambut, gigi, dan bercukur
4 Berpakaian (Dressing)
0 = Tergantung dengan orang lain1 = sebagian dibantu (seperti mengancing baju)2 = Mandiri
5 Buang Air Kecil (Bladder)
0 = Inkontinensia atau pakai kateter dan tidak terkontrol1 = Kadang inkontinesia (maksimal, 1x24 jam)2 = Kontinensia (teratur untuk lebih dari 7 hari)
6 Buang Air Besar (Bowel)
0 = Inkontinensia ( tidak teratur atau perlu enema)1 = Kadang inkontinensia (seminggu sekali)2 = Kontinensia (teratur)
7 Pengguanaan Toilet
0 = Tergantung bantuan orang lain1 = Membutuhkan bantuan, tapi dapat melakukan beberapa hal sendiri2 = Mandiri
8 Transfer 0 = Tidak mampu
1 = Butuh bantuan untuk bisa duduk (2orang)2 = Bantuan kecil(1 orang)3 = Mandiri
9 Mobilitas 0 = Imobilitas (tidak mampu)1 = Menggunakan kursi roda2 = Berjalan dengan bantuan 1 orang3 = Mandiri (meskipun menggunakan alat bantu dengan tongkat)
10 Naik Turun Tangga
0 = Tidak mampu1 = Membutuhkan bantuan (alat bantu)2 = Mandiri
Interpretasi Hasil :
20 : Mandiri
12-19 : Ketergantungan Ringan
9-11 : Ketergantungan Sedang
5-8 : Ketergantungan Berat
0-4 : Ketergantungan Total
O. PENGKAJIAN STATUS MENTAL GERONTIK1. Identifikasi tingkat intelektual dengan Short Protable Mental Status
Quesioner (SPMSQ)
Skor No
Pertanyaan Jawaban+ -
1 Tanggal berapa hari ini ?2 Hari apa sekarang ?3 Apa nama tempat ini?4 Dimana alamat anda?5 Berapa umur anda?6 Kapan anda lahir?7 Siapa presiden Indonesia sekarang?8 Siapa presiden sebelumnya?9 Siapa nama ibu anda?10 Berapa 20 dikurang 3? (seterusnya sampai
bilangan terkecilKeterangan:Kesalahan 0-2 : Fungsi Intelektual UtuhKesalahan 3-4 : Kerusakan Intelektual RinganKesalahan 5-7 : Kerusakan Intelektual SedangKesalahan 8-10 : Kerusakan Intelektual Berat
2. Identifikasi aspek kognitif dari fungsi mental dengan Mini Mental Status Exam (MMSE)
Nilai Maksimum Nilai Pasien PertanyaanOrientasi
5 (Hari) (Tanggal) (Bulan) (Tahun Sekarang)5 Dimana kita (Negara) (Wilayah) (Kota) (Desa)
(Banjar)Registrasi
3 Sebutkan nama 3 objek : 1 detik untuk menyatakan masing-masing. Beri 1 poin untuk setiap jawaban yang benar
Perhatian dan Kalkulasi5 Seri 7’s 1 poin untuk setiap kebenaran. Berhenti
setelah 5 jawaban. Berganti eja “kata” ke belakang
Mengingat3 Meminta untuk mengulang ketiga objek di atas.
Berikan 1 poin untuk setiap kebenaranBahasa
9 Nama pensil dan melihat (2 poin)Mengulang hal berikut : tidak ada jika, dan atau tetapi (1 poin)Nilai Total
Keterangan :
Nilai maksimal 30
Nilai 21 atau kurang indikasi adanya kerusakan kognitif
P. PENGKAJIAN RESIKO JATUH
SKALA MORSE
No Item Penilaian TanggalJamSkor 1 2 3 4
1 Usiaa. Kurang dari 60b. Lebih dari 60c. Lebih dari 80
012
2 Deficit sensoria. Kacamata bukan
bifokalb. Kacamata bifokalc. Gangguan pendengarand. Kacamata multifokale. Katarak/glaukomaf. Hampir tidak
melihat/buta
011223
3 Aktivitasa. Mandirib. ADL dibantu sebagianc. ADL dibantu penuh
023
4 Riwayat Jatuha. Tidak pernahb. Jatuh< 1 tahunc. Jatuh < 1 buland. Jatuh pada saat di
rawat sekarang
0123
5 Kognisia. Orientasi baikb. Kesulitan mengerti
perintahc. Gangguan memorid. Kebingungane. Disorientasi
02
233
6 Pengobatan dan penggunaan alat kesehatan
a. > 4 jenis pengobatanb. Antihipertensi/
hipoglikemik/antidepresan
c. Sedatif/psikotropika/narkotika
12
2
2
d. Infuse/epidural/spinal/dower chateter/traksi
7 Mobilitasa. Mandirib. Menggunakan alat
bantu berpindahc. Koordinasi/
keseimbangan memburuk
d. Dibantu sebagiane. Dibantu
penuh/bedrest/nurse asist
f. Lingkungan dengan banyak furniture
01
2
34
4
8 Pola BAB/BAKa. Teraturb. Inkontinensia urine /
fesesc. Nokturiad. Urgensi/frekuensi
01
23
9 Komorbidibitasa. Diabetes/penyakit
jantung/stroke/ISKb. Gangguan saraf pusat/
parkinsonc. Pasca bedah 0-24 jam
2
2
3
Total SkorKeterangan
Resiko rendah 0-7Risiko Tinggi 8-13Risiko sangat tinggi ≥ 14
Q. INFORMASI PENUNJANG1. Laboratorium
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2. Radiologi................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Diagnosa Medis........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4. Terapi medis, obat dan lain-lain........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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II. ANALISIS DATA
No DATA FOKUS ETIOLOGI PROBLEM
III. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS MASALAH
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