askep resume baru
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ASKEP RESUME
Nama Klien : ............................... No CM : .................................
Usia : ............................... Jenis Kelamin: .................................
Alamat : ............................... Tanggal Pengkajian : .....................
A. Data Klien
Riwayat Penyakit Sekarang:
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Riwayat Penyakit Dulu :
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.............................................................................................................................B. Hasil Pengkajian Saat ini
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C. Masalah Keperawatan yang Muncul
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Data Masalah Etiologi
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D. Rencana Keperawatan No Diagnosa NOC NIC
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.E. Implementasi
No Diagnosa Implementasi Evaluasi Paraf...................................... ................... ................... ................... ................... ................... ......
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..............................................O: ...................................................................................... .............................................................................................................................................................................................................................................................................................................................................................................................................................. .......................................................................................................................................... ..............................................A: ..............................................................................................................................................................................................................................................................................P: ...........................................................................................................................................................................................................................................................................................................................................................................
SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ)
PENILAIAN UNTUK MENGETAHUI FUNGSI INTELEKTUAL LANSIA
Nama klien : ....................................... Tanggal : ..............................
Jenis kelamin : ....................................... Umur : ........ tahun
Agama : ....................................... Suku : ...............................
Alamat : .......................................
Pewawancara : .......................................
Skor
NO Pertanyaan Jawaban+ -
1 Tanggal berapa hari ini?
2 Hari apa sekarang ini?
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 kecil ibu anda?
10 Kurang 3 dari 20 dan tetap
pengurangan 3 dari setiap angka
baru, semua secara menurun !
Jumlah Kesalahan Total
Kesimpulan :
APGAR KELUARGA DENGAN LANSIA
SKRINING UNTUK MELENGKAPI PENGKAJIAN FUNGSI SOSIAL
Nama klien : ....................................... Tanggal : ...........................
Jenis kelamin : ....................................... Umur : ........... tahun
Agama : ....................................... Suku : ............................
Alamat : .......................................
NO U r a i a n Fungsi Skor
1 Saya puas bahwa saya dapat kembali pada keluarga (teman –
teman) saya untuk membantu pada waktu sesuatu
menyusahkan saya
Adaptation 1
2 Saya puas dengan cara keluarga (teman – teman) saya
membicarakan sesuatu dengan saya dan mengungkapkan
masalah dengan saya
Partneship 1
3 Saya puas bahwa keluarga (teman – teman) saya menerima
dan mendukung keinginan saya untuk melakukan aktivitas
atau arah baru
Growth 1
4 Saya puas dengan cara keluarga (teman – teman) saya
mengekspresikan afek dan berespon terhadap emosi – emosi
saya seperti marah, sedih atau mencintai
Affection 1
5 Saya puas dengan cara teman – teman saya dan saya
menyediakan waktu bersama – sama
Resolve 1
Ket. Selalu = 2, Kadang – kadang = 1, Hampir tidak
pernah = 0
Total 5
Kesimpulan :
INVENTARIS DEPRESI BECK
MENGETAHUI TINGKAT DEPRESI LANSIA
Nama klien : ....................................... Tanggal : .......................................
Jenis kelamin : ....................................... Umur : ......... tahun
Agama : ....................................... Suku : .......................................
Alamat : .......................................
Skor U r a i a nA. Kesedihan
3 Saya sangat sedih/tidak bahagia dimana saya tak dapat menghadapinya2 Saya galau/sedih sepanjang waktu dan saya tidak dapat keluar darinya1 Saya merasa sedih atau galau0 Saya tidak merasa sedih
B. Pesimisme3 Saya merasa bahwa masa depan adalah sia – sia dan sesuatu tidak dapat membaik2 Saya merasa tidak mempunyai apa – apa untuk memandang ke depan1 Saya merasa berkecil hati mengenai masa depan0 Saya tidak begitu pesimis atau kecil hati tentang masa depan
C. Rasa kegagalan3 Saya benar – benar gagal sebagai orang tua (suami/istri)2 Bila melihat kehidupan ke belakang semua yang dapat saya lihat hanya kegagalan1 Saya merasa telah gagal melebihi orang pada umumnya0 Saya tidak merasa gagal
D. Ketidakpuasan3 Saya tidak puas dengan segalanya2 Saya tidak lagi mendapatkan kepuasan dari apapun1 Saya tidak menyukai cara yang saya gunakan0 Saya tidak merasa tidak puas
E. Rasa bersalah3 Saya merasa seolah – olah sangat buruk atau tidak berharga2 Saya merasa sangat bersalah1 Saya merasa buruk/tak berharga sebagai bagian dari waktu yang baik0 Saya tidak merasa benar – benar bersalah
F. TIdak menyukai diri sendiri3 Saya benci diri saya sendiri2 Saya muak dengan diri saya sendiri1 Saya tidak suka dengan diri saya sendiri0 Saya tidak merasa kecewa dengan diri sendiri
G. Membahayakan diri sendiri3 Saya akan membunuh diri saya sendiri jika saya mempunyai kesempatan
2 Saya mempunyai rencana pasti tentang tujuan bunuh diri1 Saya merasa lebih baik mati0 Saya tidak mempunyai pikiran – pikiran mengenai membahayakan diri sendiri
H. Menarik diri dari social3 Saya telah kehilangan semua minat saya pada orang lain dan tidak perduli pada
mereka2 Saya telah kehilangan semua minat saya pada orang lain dan mempunyai sedikit
perasaan pada mereka1 Saya kurang berminat pada orang lain dari pada sebelumnya0 Saya tidak kehilangan minat pada orang lain
I. Keragu – raguan3 Saya tidak dapat membuat keputusan sama sekali2 Saya mempunyai banyak kesulitan dalam membuat keputusan1 Saya berusaha mengambl keputusan0 Saya membuat keputusan yang baik
J. Perubahan gambaran diri3 Saya merasa bahwa saya jelek atau tampak menjijikan2 Saya merasa bahwa ada perubahan permanent dalam penampilan saya dan in
membuat saya tidak tertarik1 Saya kuatir bahwa saya tampak tua atau tidak menarik0 Saya merasa bahwa saya tampak lebih buruk dari pada sebelumnya
K. Kesulian kerja3 Saya tidak melakukan pekerjaan sama sekali2 Saya telah mendorong diri saya sendiri dengan keras untuk melakukan sesuatu1 Saya memerlukan upaya tambahan untuk memulai melakukan sesuatu0 Saya dapat bekerja kira – kira sebaik sebelumnya
L. Keletihan3 Saya sangat lelah untuk melakukan sesuatu2 Saya merasa lelah untuk melakukan sesuatu1 Saya merasa lelah dari yang biasanya0 Saya tida merasa lebih lelah dari biasanya.
M. Anoreksia3 Saya tidak mempunyai napsu makan sama sekali2 Napsu makan saya sangat memburuk sekarang1 Napsu makan saya tidak sebaik sebellumnya0 Napsu makan saya tidak buruk dari yang biasanya.