Tanggal masuk
Nama Panti
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IV. RIWAYAT KESEHATAN KELUARGA
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V. STATUS PEMERIKSAAN FISIK
A. Keadaan Umum
1. Tanda-tanda vital :
a. TD
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b. Nadi
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c. Pernafasan :
d. Suhu
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e. Tinggi badan
f. Berat badan
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6. Mulut
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7. Leher
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8. Sistem pernafasan
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9. Sistem kardiovaskuler
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10. Sistem pencernaan
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12. Sistem integumen
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13. Ekstremitas
a. Ekstremitas atas
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b. Ekstremitas bawah
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VI. PENILAIAN PSIKOSOSIAL DAN SPIRITUAL
A. Pola interaksi dengan lingkungan
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B. Bahasa
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D. Keadaan emosi
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E. Persepsi klien tentang kondisinya
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F. Konsep diri
1. Gambaran diri
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2. Ideal diri
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3. Harga diri
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4. Peran diri
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5. Identitas diri
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G. Spiritual
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KATEGORI :
A
- Ketidaktergantungan dalam semua fungsi / keenam fungsi.
Ketidaktergantungan dalam semua hal tetapi masih ada satu fungsi yang tidak bisa
dilakukan
Ketidaktergantungan dalam semua fungsi tetapi tidak bisa mandi sendiri dan satu
tambahan fungsi lainnya.
Ketidaktergantungan dalam semua fungsi tetapi tidak bisa mandi, berpakaian, dan
satu tambahan fungsi lainnya
Ketidaktergantungan dalam semua fungsi tetapi tidak bisa mandi, berpakaian, toilet
dan satu fungsi lainnya.
Ketidaktergantungan dalam semua fungsi tetapi tidak bisa mandi, berpakaian, toilet,
bergerak dan satu fungsi lainnya.
Tergantung dalam semua fungsi tersebut
B. BARTHEL INDEKS
No
Aktifitas
2
3
4
5
6
7
8
9
10
Dengan
bantuan
5
Tanpa
bantuan
10
5-10
15
10
0
0
5
5
5
5
10
10
5
5
10
10
NO
ASPEK KOGNITIF
ORIENTASI
(Skor maksimum : 10)
REGISTRASI
(Skor maksimum : 3)
PERHATIAN
DAN
PERHITUNGAN
(Skor maksimum : 5)
DAYA INGAT
(Skor maksimum : 3)
BAHASA
(Skor maksimum : 9)
NO
ASPEK KOGNITIF
NILAI
KRITERIA
Menyebutkan dengan benar :
1. Tanggal
2. Bulan
3. Tahun
4. Hari
5. Musim
6. Panti / Rt
7. Lantai / kamar
8. Kota
9. Kabupaten
10. Propinsi Masing-masing pertanyaan bernilai 1
point
Ucapkan dengan jelas dan perlahan kata-kata
seperti : BOLA, BENDERA, POHON
dengan jarak perkata 1 detik.
Sesudah itu minta pasien mengulanginya
Jawaban pertama menentukan skor
Tetapi minta pasien mencoba terus misalnya
hingga 6x
Minta pasien menghitung mundur dari 100 dengan
selisih 7 berhenti setelah 5 jawaban
Berilah skor 1 untuk setiap jawaban yang benar
Bila tidak mampu berhitung minta lansia untuk
mengeja suatu kata dari arah belakang, contoh
RUMAH H-A-M-U-R
Minta pasien untuk mengingat kembali kata yang
ditanyakan kepadanya : BOLA, BENDERA,
POHON
Beri skor 1 untuk setiap kata yang diulang
MENYEBUTKAN
Perlihatkan arloji anda sambil menanyakan apa
ini. Ulangi hal yang sama untuk pensil, bola,
bendera, pohon (Beri skor 1 untuk setiap kata
yang benar)
Pengulangan : minta pasien mengulangi kata
BUKAN, ITU BUKAN, TETAPI,
NAMUN, TANPA Beri skor 1 bila
pengulangan benar
Perintah 3 langkah : Beri pasien secarik kertas
kosong dan katakan :
Ambil kertas ini dengan tangan kanan oma.
Lipat dua
Letakkan di lantai
Beri skor 1 point untuk setiap langkah yang
benar
NILAI
KRITERIA
MEMBACA
Tulis pada kertas kalimat : Pejamkan mata anda
dengan huruf yang cukup besar. Minta pasien
membacanya dan melakukan apa yang tertulis.
Skor 1 bila lansia membaca dan melakukannya
MENULIS
Dengan secarik kertas, minta pasien menulis
sebuah kalimat yang ditulis secara spontan
Kalimat harus mengandung Subjek + Kata kerja
serta memiliki arti.
Tata bahasa dan tanda baca dikecualikan.
Beri skor 1 untuk tulisan yang benar
MENIRU GAMBAR
Pada secarik kertas kosong, gambarlah 2 segi lima
yang saling bersentuhan, seperti ini :
Keterangan :
Tiap jawaban yang bertanda bintang dihitung 1 point
Skor 15-22
: menunjukkan depresi ringan
Skor <22
: menunjukkan depresi berat
Jakarta,..............................
(...........................................)
DATA FOKUS
SUBJEKTIF
OBJEKTIF
ANALISIS DATA
DATA
MASALAH
Tanggal
Umur
Diagnosa
keperawatan
Tujuan
Ruangan/Tempat
Kriteria hasil
Tindakan keperawatan
Paraf
:
:
Diagnosa
Keperawatan
Implementasi
Evaluasi
paraf