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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