FORMAT PENGKAJIAN PADA LANSIA

Tanggal Pengkajian :

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A. DATA BIOGRAFI

Nama :

Tempat dan Tanggal Lahir :

Pendidikan terakhir :

Agama :

Status Perkawinan :

TB/BB :

Penampilan :

Alamat :

Orang yang dekat dihubungi :

Hubungan dengan usila :

Alamat :

B. RIWAYAT GENOGRAM

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C. RIWAYAT PEKERJAAN

Pekerjaan sebelumnya :

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Alamat pekerjaan :

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Berapa jarak dari rumah :

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Alat transportasi :

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Sumber – sumber pendapatan yang lain :

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D. RIWAYAT LINGKUNGAN HIDUP

Tipe tempat tinggal :

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Jumlah kamar :

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Kondisi tempat tinggal :

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Jumlah orang yang tinggal di rumah :

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Alamat / no. telepon :

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E. RIWAYAT REKREASI

Hobbi / minat :

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Keanggotaan organisasi :

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F. SISTEM PENDUKUNG

Perawat /bidan /dokter /fisioterapi :

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Jarak dari rumah :

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Rumah sakit :

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Jaraknya :

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Perawatan sehari – hari yang dilakukan oleh keluarga :

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Lain-lain :

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G. DISKRIPSI KEKHUSUSAN

Kebiasaan ritual :

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Yang lainnya :

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H. STATUS KESEHATAN

Status kesehatan umum selama setahun yang lalu :

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Status kesehatan umum selama 5 tahun yang lalu :

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Keluhan utama :

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Pemahaman dan penatalaksanaan masalah kesehatan :

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I. AKTIVITAS HIDUP SEHARI – HARI

Oksigenasi :

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Cairan dan elektrolit :

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Nutrisi :

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Eliminasi :

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Aktifitas :

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Istirahat/tidur :

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Personal hygiene :

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Psikologis :

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Persepsi klien :

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Konsep diri :

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Emosi :

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Adaptasi :

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Mekanisme pertahanan diri :

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J. TINJAUAN SISTEM

Keadaan umum :

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Tingkat kesadaran :

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Tanda – tanda vital :

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Kepala

a. Bentuk kepala :

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Ubun-ubun :

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Kulit kepala :

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Rambut :

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Penyebaran dan keadaan rambut :

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Bau :

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Warna :

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b. Wajah :

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Warna kulit :

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Struktur wajah :

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Mata,telinga,hidung

Mata :

a. Kelengkapan dan kesimetrisan :

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b. Kelopak mata (palpebra) :

...................................................................................................................c. Konjungtiva dan sclera :

...................................................................................................................d. Pupil :

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e. Kornea dan iris :

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f. Ketajaman penglihatan/visus :

...................................................................................................................g. Tekanan bola mata :

...................................................................................................................Telinga :

a. Bentuk telinga :

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Ukuran telinga :

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Ketegangan telinga :

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b. Lubang telinga :

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c. Ketajaman pendengaran :

...................................................................................................................Hidung

a. Tulang hidung dan posisi septum nasi :

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b. Lubang hidung :

...................................................................................................................c. Cuping hidung :

...................................................................................................................Leher

a. Posisi trachea :

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b. Tiroid :

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...................................................................................................................d. Kelenjar limfe :

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e. Vena jugularis :

...................................................................................................................f. Denyut nadi karotis :

...................................................................................................................Dada dan punggung

a. Bentuk dada :

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b. Pernapasan

Frekuensi :

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Irama :

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c. Tanda-tanda kesulitan bernapas :

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d. Punggung :

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Ekstermitas atas dan bawah

a. Kesimetrisan otot :

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b. Pemeriksaan oedem :

...................................................................................................................c. Kekuatan otot :

...................................................................................................................d. Kelainan-kelainan pada ekstremitas :

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Genetalia

1. Genetalia

a. Rambut pubis :

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b. Meatus urethra :

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c. Kelainan-kelainan pada genetalia eksterna dan daerah inguinal :

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2. Anus dan perineum

a. Lubang anus :

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b. Kelainan-kelainan pada anus :

............................................................................................................c. Perineum :

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System persyarafan

a. Tingkat kesadaran (secara kuantitatif)/GCS :

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b. Tanda-tanda rangsangan otak :

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c. Syaraf otak (Nervus Cranialis)

N.I :

N.II :

N.III :

N.IV :

N.V :

N. VI :

N.VII :

N.VIII :

N.IX :

N.X :

N.XI :

N.XII :

Sistem pengecapan :

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Sistem penciuman :

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Tactil respon :

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K. STATUS KOGNITIF/AFEKTIF/SOSIAL

1. SPMSQ :

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2. MMSE :

...................................................................................................................3. INVENTARIS DEPRESI BACK :

...................................................................................................................4. APGAR KELUARGA :

...................................................................................................................5. INDEKS KATZ :

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L. DATA PENUNJANG

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…………………....,……………………….

(……………………………………………..)

INDEKS KATZ

( INDEKS KEMANDIRIAN PADA AKTIVITAS SEHARI – HARI )

SCORE KRITERIA

AKEMANDIRIAN DALAM HAL MAKAN, KONTINEN,

BERPINDAH, KE KAMAR KECIL, BERPAKAIAN DAN MANDI

BKEMANDIRIAN DALAM SEMUA AKTIVITAS SEHARI – HARI,

KECUALI SATU DARI FUNGSI TERSEBUT

CKEMANDIRIAN DALAM SEMUA AKTIVITAS, KECUALI

MANDI DAN SATU FUNGSI TAMBAHAN

DKEMANDIRIAN DALAM SEMUA AKTIVITAS, KECUALI

MANDI, BERPAKAIAN, DAN SATU FUNGSI TAMBAHAN

E

KEMANDIRIAN DALAM SEMUA AKTIVITAS, KECUALI

MANDI, BERPAKAIAN, KE KAMAR KECIL DAN SATU FUNGSI

TAMBAHAN

F

KEMANDIRIAN DALAM SEMUA AKTIVITAS SEHARI – HARI,

KECUALI MANDI, BERPAKAIAN, KE KAMAR KECIL,

BERPINDAH DAN SATU FUNGSI TAMBAHAN

G KETERANGAN PADA KE ENAM FUNGSI TERSEBUT

LAIN – LAINTERGANTUNG PADA SEDIKITNYA 2 FUNGSI, TETAPI TIDAK

DAPAT DIKLASIFIKASIKAN SEBAGAI C, D, E, ATAU F

SHORT PORTABLE MENTAL STATUS QUESTIONAIRE

(SPMSQ)

( PENILAIAN INI UNTUK MENGETAHUI FUNGSI INTELEKTUAL MANULA)

SKORENO PERTANYAAN JAWABAN

0 1

1 TANGGAL BERAPA HARI INI ?

2 HARI APA SEKARANG ?

3 APA NAMA TEMPAT INI ?

4 BERAPA NO TELP ANDA ?

4A, DIMANA ALAMAT ANDA ?

(TANYAKAN BILA TAK ADA

NO TELP).

5 BERAPA UMUR ANDA ?

6 KAPAN ANDA LAHIR ?

7 SIAPA PRESIDEN INDONESIA

SEKARANG ?

8 SIAPA PRESIDEN

SEBALUMNYA ?

9 SIAPA NAMA KECIL IBU

ANDA ?

10 KURANGI 3 DARI 20 DAN

TETAP PENGURANGAN 3 DARI

SETIAP ANGKA BARU SEMUA

SECARA MENURUN ?

JUMLAH KESALAHAN TOTAL

KETERANGAN :

1. KESALAHAN 0 -2 : FUNGSI INTELEKTUAL UTUH

2. KESALAHAN 3 – 4 : KERUSAKAN INTELEKTUAL RINGAN

3. KESALAHAN 5 – 7 : KERUSAKAN INTELEKTUAL

SEDANG

4. KESALAHAN 8 – 10 : KERUSAKAN INTELEKTUAL BERAT

MINI MENTAL STATE EXAM ( MMSE )

Nilai Pasien Pernyataan

Maksimum

Orientasi

5 (tahun), (musim),(tanggal), (hari), (bulan apa sekarang)

5 Dimana kita (propinsi),(wilayah),(kota),(rumah sakit),

(lantai)

Regristrasi

3 Nama 3 obyek: 1 detik untuk masing – masing kemudian

tanyakan klien ketiga obyek setelah anda telah

mengatakannya beri 1 poin untuk setiap jawaban yang

benar kemudian ulangi sampai ia mempelajari ketiganya,

jumlahkan percobaan dan catat

Perhatikan dan kalkulasi

5 Seri 7,1 poin untuk setiap kebenaran berhenti setelah 5

jawaban

Mengingat

3 Minta untuk mengulangi tiga obyek diatas

Bahasa

9 Nama pensil dan melihat ( 2 poin )

Mengulang hal berikut : tak ada jika, dan atau tetap ( 1

poin )

Nilai total

(MENGUJI ASPEK KOGNITIF DARI FUNGSI MENTAL )

KUISONER TINGKAT DEPRESI

JAWABLAH PERTANYAAN DIBAWAH INI DENGAN MEMBERIKAN TANDA (√) PADA

JAWABAN YA/TIDAK DENGAN YANG ANDA RASAKAN

NO PERTANYAANJAWABAN

YA TIDAK

1 APAKAH ANDA PUAS DENGAN KEDIDUPAN ANDA ?

2 APAKAH SAAT INI ANDA SUDAH KEHILANGAN BERAKTIVITAS

DAN MINAT-MINAT ANDA ?

3 APAKAH ANDA MERASA HIDUP ANDA KOSONG ?

4 APAKAH ANDA SERING MERASA BOSAN ?

5 APAKAH ANDA SELALU SEMANGAT ??

6 APAKAH ANDA TAKUT BAHWA SUATU HAL YANG BURUK AKAN

MENIMPA ANDA

7 APAKAH ANDA MERASA GEMBIRA DALAM SEBAGAIAN BESAR

WAKTU ANDA ?

8 APAKAH ANDA SERING MERASA TIDAK ADA YANG BISA

MEMBANTU ?

9 APAKAH ANDA LEBIH TIDAK SUKA TINGGAL DIRUMAH,

DARIPADA KELUAR DAN MENGERJAKAN SESUATU HAL YANG

BARU ?

10 APAKAH ANDA BERFIKIR BAHWA ANDA MENGALAMI

GANGGUAN INGATAN LEBIH PARAH DARIPADA ORANG LAIN ?

11 APAKAH ANDA BERFIKIR BAHWA TETAP HIDUP SAAT INI

MERUPAKAN HAL YANG SANGAT MENYENANGKAN ?

12 APAKAH ANDA BERFIKIR BAHWA SAAT INI ANDA BENAR –

BENAR TIDAK BAHAGIA ?

13 APAKAH ANDA MERASA DIRI ANDA PENUH ENERGI?

14 APAKAH ANDA MERASA BAHWA KEADAAN ANDA SAAT INI

SUDAH TIDAK ADA HARAPAN ?

15 APAKAH ANDA BERFIKIR BAHWA SEBAGAIAN BESAR ORANG

LEBIH BAIK DARIPADA DIRI ANDA SENDIRI ?

KUNCI JAWABAN KOESIONER TINGKAT DEPRESI

NO JAWABAN

1 TIDAK

2 YA

3 YA

4 YA

5 TIDAK

6 YA

7 TIDAK

8 YA

9 YA

10 YA

11 TIDAK

12 YA

13 TIDAK

14 YA

15 YA

0 – 5 : SUSPECT DEPRESI

6 – 15 : DEPRESI

APGAR KELUARGA

ALAT SIRINING SINGKAT YANG DI GUNAKAN UNTUK MENGKAJI FUNGSI SOSIAL

NO URAIAN FUNGSI SKORE

1 SAYA PUAS KARENA SAYA DAPAT KEMBALI

DENGAN KELUARGA (TEMAN-TEMAN) SAYA

UNTUK MEMBANTU PADA WAKTU SESUATU

MENYUSAHKAN SAYA

ADAPTATION

2 SAYA PUAS DENGAN CARA KELUARGA

(TEMAN-TEMAN) SAYA MEMBICARAKAN

SESUATU DENGAN SAYA DAN

MENGUNGKAPKAN MASALAH DENGAN

SAYA

PARTNERSHIP

3 SAYA PUAS DENGAN KELUARGA (TEMAN-

TEMAN) SAYA MENERIMA DAN

MENDUKUNG KEINGINAN SAYA UNTUK

MELAKUKAN AKTIVITAS ATAU ARAH BARU

GROWTH

4 SAYA PUAS DENGAN CARA KELUARGA

(TEMAN-TEMAN) SAYA MENGEPRESIKAN

EFEK DAN BERESPON TERHADAP EMOSI

SAYA, SEPERTI MARAH, SEDIH ATAU

MENCINTAI

AFFECTION

5 SAYA PUAS DENGAN CARA (TEMAN-TEMAN)

SAYA DAN SAYA MENYEDIAKAN WAKTU

BERSAMA – SAMA

RESOLVE

PENILAIAN

PERTANYAAN – PERTANYAAN YANG

DIJAWAB :

SELALU : SKORE 2

KADANG2 : SKORE 1

HAMPIR TIDAK PERNAH : SKORE 0

TOTAL