ASUHAN KEPERAWATAN GERONTIK

Nama mahasiswa

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NIM

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Tempat Praktik

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Tanggal Pengkajian

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PENGKAJIAN
I. Identitas Kepala Keluarga
Nama

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Umur

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Agama

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Pekerjaan

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Pendidikan

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Suku atau bangsa

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Alamat

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II. Keluhan Umum

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III. Riwayat Kesehatan

a. Masalah kesehatan yang pernah dialami dan dirasakan saat ini
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b. Masalah kesehatan keluarga/keturunan

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IV. Kebiasaan Sehari-hari

a. Biologis
1. Pola Makan
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2. Pola Minum
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3. Pola Tidur
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4. Pola eliminasi (BAB/BAK)

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5. Aktivitas sehari-hari
Kemampuan Perawatan Diri

Kemampuan melakukan ROM

Kemampuan Mobilitas di tempat tidur
Kemampuan makan/minum
Kemampuan toieting
Kemampuan Mandi
Kemampuan berpindah
Kemampuan berpakaian
Ket. : 0 = Mandiri

1= Menggunakan alat bantu 2 = dibantu orang lain

3 = Dibantu orang lain dan alat

4 = Tergantung Total

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6. Rekreasi
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7. Indeks KATZ
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b. Psikologis
1. Mental (SPMSQ)
Short Portabel Mental Status Questionaire (SPMSQ)
Skore
+

N0

Pertanyaan

1.

Tanggal berapa hari ini?

2.

Hari apa sekarang ini?

3.

Apa nama tempat ini?

4.

Berapa nomer telepon anda?

4a.

Dimana alamat anda? Tanyakan hanya klien tidak

mempunyai telepon

Berapa umur anda?

Kapan anda lahir?

Siapa presiden indonesia sekarang?

Siapa presiden sebelumnya?

Siapa nama kecil ibu anda?

10

Kurangi 3 dari 20 dam tetap pengurangan 3 dari

setiap angka baru, semua secara menurun

Jumlah kesalahan total

Penilaian SPMSQ :
Kesalahan 8 - 10 fungsi intelektual berat
Kesalahan 5 7 fungsi intelektual sedang
Kesalahan 3 - 4 fungsi intelektual ringan
Kesalahan 0 - 2 fungsi intelektual utuh

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2. Depresi (Yesavage)
Skala Depresi Geriatrik Yesavage, bentuk singkat
Pertanyaan

1. Apakah pada dasarnya anda puas dengan kehidupan anda?

(Tidak)

Jawaban klien

Nilai

2. Sudahkah anda mengeluarkan aktivitas dan minat anda?

(Ya)
3. Apakah anda merasa bahwa hgidup anda kosong? (Ya)
4. Apakah anda sering bosan? (Ya)
5. Apakah anda mempunyai semangat yang baik setiap
waktu? (Tidak)
6. Apakah anda takut sesuatu akan terjadi pada anda? (Ya)
7. Apakah anda merasa bahagia setiap waktu? (Tidak)
8. Apakah anda lebih suka tinggal di rumah pada malam hari,
daripada pergi dan melakukan sesuatu yang baru? (Ya)
9. Apakah anda merasa bahwa anda mempunyai lebih banyak
masalah dengan ingatan anda daripada yang lainnya? (Ya)
10. Apakah anda berfikir sangat menyenangkan hidup
sekarang ini? (Tidak)
11. Apakah anda merasa saya sangat tidak berguna sengan
keadaan anda sekarang? (Ya)
12. Apakah anda merasa penuh berenergi? (Tidak)
13. Apakah anda berfikir bahwa situiasi anda tidak ada
harapan? (Ya)
14. Apakah anda berfikir bahwa banyak orang yang lebih baik
dari anda? (Ya)

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3. Keadaan emosi
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4. Konsep Diri
Gambaran Diri

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Ideal Diri

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Harga Diri

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Peran Diri

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Identitas Diri

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5. Apgar Skore Keluarga dengan Lansia

Status sosial lansia diukur dengan menggunakan APGAR keluarga :
APGAR Keluarga
No
1

Fungsi
Adaptasi

Uraian

Skore

Saya puas bahwa saya dapat kembali pada

keluarga (teman-teman) saya untuk membantu
pada waktu sesuatu menyusahkan saya

Hubungan

Saya puas dengan cara keluarga (teman-teman)

saya membicarakan sesuatu dengan saya dan
mengungkapkan masalah dengan saya

Pertumbuhan

Saya puas bahwa keluarga (teman-teman) saya

menerima dan mendukung keinginan saya untuk
melakukan aktivitas atau arah baru

Afeksi

Saya puas dengan cara keluarga (teman-teman)

saya

mengekspresikan

afek

dan

berespons

terhadap emosi-emosi saya, seperti marah, sedih,

atau mencintai
5

Pemecahan

Saya puas dengan cara teman-teman saya dan

saya menyediakan waktu bersama-sama

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c. Sosial
1. Dukungan Keluarga
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2. Hubungan dengan Keluarga

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3. Hubungan dengan Orang lain

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d. Spiritual/Kultural
1. Pelaksanaan Ibadah
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2. Keyakinan tentang kesehatan
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e. Pemeriksaan Fisik
Tinjauan Sistem
1. Keadaan Umum : .................................................
2. Tingkat kesadaran :
3. GCS

:E V M

4. Suhu

: ............C

5. Nadi

: .............X/mnt

6. Tekanan darah

: .............mmHg

7. Pernapasan

: .............X/mnt

8. Tinggi badan

: ..............cm

9. Berat badan

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10. Kepala/rambut

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11. Mata, telinga, hidung dan mulut :

Mata

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Telinga

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Hidung

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Mulut :
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12. Leher

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13. Dada dan pungggung :
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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14. Abdomen :
Inspeksi :
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Auskultasi :
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Palpasi :
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Perkusi

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15. Ekstremitas atas dan bawah :
Atas
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Bawah

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