01/06/2012

ASUHAN KEPERAWATAN
GERONTIK

RAMDHANY ISMAHMUDI

TUJUAN PEMBERIAN ASUHAN :

1. Mempertahankan kesehatan serta kemampuan

melalui jalan perawatan dan pencegahan
2. Membantu
mempertahankan
serta
memperbesar semangat hidup klien lansia
3. Menolong dan merawat klien lansia yg
menderita penyakit
4. Meningkatkan kemampuan perawat dalam
melakukan proses keperawatan
5. Melakukan kegiatan sehari-hari secara mandiri
dengan upaya promotif, preventif dan
rehabilitatif
6. Membantu lansia menghadapi kematian dengan
damai dan dalam lingkungan yang nyaman

DEFINISI

SASARAN

ASUHAN KEPERAWATAN LANSIA ADALAH

SUATU RANGKAIAN KEGIATAN DARI
PROSES KEPERAWATAN YANG DITUJUKAN
KEPADA LANSIA
KEGIATAN TERSEBUT MELIPUTI :

Sasaran asuhan kepr. Pada lansia

adalah :

PENGKAJIAN
BIOFISIK
PSIKOLOGIS
KULTURAL
SPIRITUAL

DIAGNOSA
INTERVENSI
IMPLEMENTASI
EVALUASI

klien lansia yang berada di keluarga,

panti
(sebagai
individu
atau
kelompok),
Masyarakat (posyandu lansia/karang
wreda)

01/06/2012

Faktor-faktor yg harus dipertimbangkan

dlm pemberian askep :

INTERACTING DIMENSIONS OF GERIATRIC

ASSESSMENT.

1. Hubungan timbal balik antara aspek fisik dan

psikososial pada lansia
2. Efek dari penyakit dan ketidakmampuan/keterbatasan
(disability) pada status fungsional
3. Menurunnya efisiensi dari mekanisme homeostatis

Contoh : respon terhadap stres menurun sehingga mudah

terinfeksi dan sulit menghadapi kematian pasangan

4. Kurang/belum adanya standar keadaan sehat atau

sakit dari klien
5. Perubahan respon terhadap penyakit di mana tanda
dan gejalanya tidak spesifik thd pengobatan
6. Kerusakan fungsi kognitif

Contoh : pelupa (memory loss), bingung

PENGKAJIAN LANSIA

FUNCTIONAL
PHYSICAL
COGNITIVE
PSYCHOLOGY
SOCIAL
SPIRITUAL

FUNCTIONAL ASESSMENT
Nurses typically conduct a functional assess-ment in order
to identify an older adults ability to perform self-care,
self-maintenance, and physical activities, and plan
appropriate nursing interventions.
There are two approaches. One approach is to ask
questions about ability and the other approach is to
observe ability through evaluating task completion.
However, although we tend to speak of ability, our
verbal and observational tools tend to screen for disability.

01/06/2012

CONT

Cont

Disability refers to the impact that health problems

have on an individuals ability to per-form tasks,
roles, and activities, and it is often measured by
asking questions about the per-formance of
activities of daily living (such as eat-ing and
dressing) and instrumental activities of daily living
(such as meal preparation and hob-bies)
(Verbrugge & Jette, 1994).
The basis of our understanding of ability, disability,
physical function, activities of daily living, and any
con-textual factors comes from work initiated by the
World Health Organization (WHO) more than 25
years ago

Functional assessments serve as the

common language of health for patients,
family members, and health care
providers of older adults.
The ability to manage day-to-day activities
such as eating, bathing, ambulating,
manag-ing money, and keeping track of
medications serves as the foundation of
safe, independent functioning for all
adults.

Cont

ICIDH Classification WHO (1980)

Physical functioning is a dynamic

process of interaction between
individuals
and
their
environments.
The process is influenced by
motivation, physical ca)pacity,
illness, cognitive ability, and the
external environment including
social supports.

IMPAIRMENT: Any loss or abnormality of

psychological, physiological, or anatomical structure or
function.
DISABILITY: Any restriction or lack (result-ing from
impairment) of ability to per-form an activity in the
manner or within the range considered normal for a
human being.
HANDICAP: A disadvantage for a given individual,
resulting from impairment or disability that limits or
prevents the fulfillment of a role that is normal
(depending on age, sex, and social and cultural factors)
for that individual.

01/06/2012

TYPE FUNCTIONAL ASSESMENT

ACTIVITY
DAILY
LIVING(Bathing,
Dressing,Eating,Toileting,Hygiene, Transferring)
INSTRUMENTAL
ACTIVITIES
OF
DAILY
LIVING(Housework, Finances, Driving, Shopping,
Meal preparation, Reading, Medication, adherence,
Aware of current events, Hobbies, Employment,
Volunteer work)
MOBILITY(Balance,
sitting,
standing,
Gait
steadiness, Turns)

KARZT INDEX
ACTIVITIES

INDEPENDENCE
(1 point)
NO supervision, direction or personal
assistance

DEPENDENCE
(0 points)
WITH supervision, direction, personal
assistance or total care

BATHING

(1 POINT) Bathes self completely or needs

help in bathing only a single part of the
Point: ______ body such as the back, genital area, or
disabled extremity.

(0 POINT) Needs help in bathing more

than one part of the body getting out of
the tub or shower. Requires total bathing.

DRESSING

(1 POINT) Gets clothes from closets and

drawers and puts on clothes and other
Point: ______ garments complete with fasteners. May
have help tying shoes.

(0 POINTS) Needs help with dressing self

or needs to be completely dressed.

TOILETING

(1 POINT) Goes to toilet, gets on and off,

arranges clothes, cleans genital area
Point: ______ without help.

(0 POINTS) Needs help transferring to the

toilet, cleaning self or uses bedpan or
commode.

TRANSFERRING

(1 POINT) Moves in and out of bed or chair

unassisted. Mechanical transferring aides
Point: ______ are acceptable.

(0 POINTS) Needs help in moving from

bed to chair or requires a complete
transfer.

CONTINENCE

(1 POINT) Exercises complete self control

over urination and defecation.

(0 POINTS) Is partially or totally

incontinent of bowel or bladder.

Point: ______
FEEDING

(1 POINT) Gets food from plate into mouth

without help. Preparation of food may be
Point: ______ done by another person.

TOTAL POINTS= _____

6 = High(patient independent)

(0 POINTS) Needs partial or total help

with feeding or requires parenteral
feeding.
0 = Low (patient very dependent)

PHYSICAL ASSESMENT

Circulatory Function
Respiratory Function
Gastrointestinal Function
Genitourinary Function
Sexual Function
Neurological Function
Musculoskeletal Function
Sensory Function
Integumentary Function
Endocrine and Metabolic Function
Hematology and Immun Functioan

01/06/2012

ASSESS COGNITIVE FUNCTION

COGNITIVE ASSESMENT

THE GOALS OF COGNITIVE ASSESSMENT INCLUDE

To determine an individuals
cognitive abilities.
To recognize early the presence
of an impairment in cognitive
functioning.
To monitor an individuals
cognitive response to various
treatments

Mini-Mental State Examination (Folstein et al., 1975 [Level IV]) can be

used to screen for or monitor cognitive function in-strument; however,
performance on the MMSE is adversely in-fluenced by education, age,
language, and verbal ability. The MMSE also is criticized for taking too
long to administer and score.
Mini-Cog (Borson et al., 2000 [Level IV]) also can be used to screen and
monitor cognitive function; is not adversely influ-enced by age,
language, and education; and it takes about half as much time to
administer and score as the MMSE.
IQCDE is useful to supplement testing with the MMSE or Mini-Cog
because it is useful to determine onset, duration, and functional impact
of the cognitive impairment. Information from intimate others can be
obtained by using the Informant Question-naire on Cognitive Decline in
the Elderly (IQCDE) (Jorm, 1994 Level IV].
Naturally occurring interactions: Observations and conversations during
naturally occurring care interactions can be the impetus for additional
screening/monitoring of cognitive function with the MMSE or Mini-Cog
(Foreman et al., 2003 [Level VI])

WHEN TO ASSESS COGNITIVE FUNCTION

On admission to and discharge from an institutional care
setting.
On transfer from one care setting to another.
During hospitalization, every 8 to 12 hours throughout
hospitalization.
As follow-up to hospital care, within 6 weeks of discharge.
Before making important health care decisions as an
adjunct to determining an individuals capacity to consent
On the first visit to a new care provider.
Following major changes in pharmacotherapy
With behavior that is unusual for the individual and/or
inappro-priate to the situation

01/06/2012

PSYCHOLOGICAL ASSESSMENT

DEPRESSION

Psychological assessment of older adults

presents a wide continuum from positive
mental health to mental health problems,
and the tendency seems to be weighted
toward assessment of mental health
disorders.
Are two areas of psychological assessment:
quality of life, which may include several
positive mental health constructs, and
depression, a common mental health
problem.

The prevalence of clinical depression in older Americans is

estimated to be from 5%10% among communitydwelling
individuals,
30%40%
among
recently
hospitalized
individuals, and 15%30% among older persons residing in
long-term care facilities (Lebowitz et al., 1997).
Depressed older adults may experience difficulty with
sleeping, loss of appetite, physical discomfort, anxiety,
hopelessness, bouts of crying, and suicide ideation. They may
feel uncomfortable in social situations and curtail their usual
social contacts and events, creating a downward spiral of
depression and isolation.
Depression is associated with cognitive limitations, and
depressed older adults can experience disorientation,
shortened attention span, emotional outbursts, and difficulty
in intellectual functioning.

QUALITY OF LIFE

SCREENING TOOLS FOR DEPRESSION

Elements of successful aging have

included
self-acceptance,
positive
relationships with others, and personal
growth.
Quality of life encompasses all areas of
everyday life: environmental and
material components, and physical,
mental, and social well-being (Fletcher,
Dickinson, & Philp, 1992)

Without
significant
cognitive
impairment in general medical or
geriatric settings include:
Geriatric
Depression
Scale
(GDS)
SELFCARE
Brief Assessment Schedule Depression
Cards (BASDEC) for hospitalized patients.

Moderate
to
severe
cognitive
impairment:
Cornell
Scale
for
Depression in Dementia

01/06/2012

Part 1: Risk Screening

1 IS MY PATIENT AT RISK FOR DEPRESSION?
National Guidelines for Seniors Mental Health: Part 2: 2.1.1
PREDISPOSING FACTORS
Female
Widowed or divorced
Previous depression history
Brain changes due to vascular problems
Major physical and chronic disabling illnesses
Medications or Polypharmacy
Excessive alcohol use
Social disadvantage & low social support
Caregiver for person with a major disease (e.g.,dementia)
Personality type (e.g., relationship or dependence problems)

PRECIPITATING FACTORS
Recent bereavement
Move from home to other places (e.g., nursing home)
Adverse life events (e.g., losses, separation, financial crisis)
Chronic stress with declining health, family or marital problems
Social isolation
Persistent sleep difficulties

2 RECOMMENDED ASSESSMENT OPTIONS

National Guidelines for Seniors Mental Health: Part 2: 2.1.2
A structured interview using one of the following tools:
TOOLS DEVELOPED TO REFLECT DEPRESSION OLDER ADULTS WITH AVAILABLE
WEBSITES

Part 1:
RISK, SCREENING

In general medical practice, nursing/residential homes or inpatient settings

SIG E CAPS(http://webmedia.unmc.edu/intmed/geriatics/reynolds/pearlcards/depression/depressionin
dex.htm)
The Geriatric Depression Scale
(http://www.stanford.edu/~yesavage/GDS.html)
Brief Assessment Schedule for the Elderly (BASDEC)
(http://www.medalreg.com/www/sheets/ch18/depression%20Koenig%20scale.xls)
In community surveys
Center for Epidemiological Studies Depression Scale
The Geriatric Mental State Schedule (GMSS)
For depression in the presence of dementia or significant cognitive difficulties
The Cornell Scale for Depression in Dementia
(http://www.emoryhealthcare.org/departments/fuqua/CornellScale.pdf )

01/06/2012

3 DIAGNOSTIC CRITERIA
National Guidelines for Seniors Mental Health: Part 2: 2.2
DIAGNOSTIC CRITERIA FOR DEPRESSION - DSM 1+V )
A cluster of symptoms present on most days, most of the
time, for at least 2 weeks
Depressed mood
Loss of interest or pleasure in normal, previously enjoyed activities
Decreased energy and increased fatigue
Sleep disturbance
Inappropriate feelings of guilt
Diminished ability to think or concentrate
Appetite change (i.e., usually loss of appetite in the elderly)
Psychomotor agitation or retardation
Suicidal ideation or recurrent thoughts of death

4 SUICIDE RISK
National Guidelines for Seniors Mental Health: Part 2: 2.1
Non-modifiable risk factors
Old age
Male gender
Being widowed or divorced
Previous attempt at self-harm
Losses (e.g., health status, role, independence,
significant relations)
Potentially modifiable risk factors
Social isolation
Presence of chronic pain
Abuse/misuse of alcohol or other medications
Presence & severity of depression
Presence of hopelessness and suicidal ideation
Access to means, especially firearms
Behaviors to alert clinicians to potential suicide
Agitation
Giving personal possessions away
Reviewing ones will
Increase in alcohol use
Non-compliance with medical treatment
Taking unnecessary risk
Preoccupation with death

DSM IV-TR CLASSIFICATION (APA, 2000)

Make a clear DSM-IV diagnosis & document
Different types of depressive disorders
Major depressive episodes
(i.e., part of unipolar, bipolar mood disorder or secondary to
a medical condition)
Dysthymic disorder
Depressive disorders not otherwise specified:
A group of disorders including minor depressive
disorder, post psychotic depressive disorder of
schizophrenia and depressive disorders of unclear
etiology (e.g., may be primary or secondary to a
medical condition or substance induced)

Part 2:
WHEN TO TREAT, REFER, &
MONITORING & LONG TERM
TREATMENT

01/06/2012

Commonly-used Antidepressant MedicationsNational Guidelines for Seniors Mental Health: Part 5

Generic
Name

Trade
Name

Starting dose
mg/day

Average
Dose

Maximum
recommended
dose (CPS)

Comments/Caution

SSRI
Citalopram

10

20-40

40 mg

Escitalopram Cipralex

Celexa

10-20

20 mg

Sertraline

25

50-150

200 mg

Zoloft

Other Agents
Buproprion

Wellbutrin 100

100 mg BID 150 mg BID

Mirtazapine

Remeron

15

30-45

Moclobemide Manerix

150

150-300 BID 300 mg BID

Venlafaxine

37.5

75-225

Effexor

May cause seizures

45 mg

*375 mg

Norpramin 10-25

50-150

300 mg

Nortriptyline

Aventyl

40-100

200 mg

10-25

National Guidelines for Seniors Mental Health: Part 4 & 5

Psychotherapies & Psychosocial Interventions
Supportive care should be offered to all patients who are depressed
Psychotherapy is a first line of treatment or in combination with antidepressant medication
Based on type of depression, coping style, level of cognitive functioning
Psychotherapy provided by trained mental health professionals
Pharmacological Treatment
Medications are used in combination with psychosocial or psychotherapy treatments
Part of overall treatment of depressed older adults
See table for commonly used antidepressants
See full guideline for details of prescribing and monitoring
7 WHEN TO REFER

Do not combine with MAO-B

inhibitors or Tricyclics
*For severe depression; May
increase blood pressure

Tricyclic Antidepressants
Desipramine

6 GUIDELINES FOR TREATMENT

Anticholinergic properties
cardiovascular side-effects;
Monitor blood levels
Anticholinergic properties;
cardiovascular side-effects;
Monitor blood levels

National Guidelines for Seniors Mental Health: Part 3: 3.5

Recommendations for clinicians to refer for Psychiatric Care at Time of Diagnosis
Psychotic depression
Bipolar disorder
Depression with suicidal ideation

5 WHEN TO TREAT

8 MONITORING AND LONG TERM TREATEMENT

National Guidelines for Seniors Mental Health: Part 2: 2.1.1

National Guidelines for Seniors Mental Health: Part 6: 3

Following a positive screen for depression a complete bio-psycho-social
assessment should be conducted including:
A review of diagnostic criteria in the DSM 1V-TR or ICD 10 manuals
An estimate of severity, including presence of psychotic or catatonic symptoms
Risk of suicide, by directly asking patients about suicidal ideation, intent and
plan
Personal or family history of mood disorder
Medication use and substance abuse
Review of current stressors and life situation
Level of functioning/disability
Family situation, social integration/support
Mental status exam, plus assessment of cognitive function
Physical exam and lab tests to determine if medical issues contribute or mimic
depressive symptoms
Treatment can be divided into 3 main phases
Acute treatment phase: to achieve remission of symptoms
Continuation phase: to prevent recurrence or relapse of same episode of illness
Maintenance or prophylaxis phase: to prevent future episodes or recurrence

Health care providers should monitor the older adult for

re-occurrence of depression for the first 2 years after treatment
Ongoing monitoring should focus on depressive symptoms present
during initial episode
Older adults in remission of their first episode should be treated for
a minimum of one year and up to 2 years from time of improvement
Older adults with recurrent episodes should receive indefinite
maintenance therapy
In LTC homes, response to therapy should be evaluated monthly
after initial improvement and then every three months, as well as
annual assessment after remission of symptoms

01/06/2012

Geriatric Depression Scale: Short Form

Are you basically satisfied with your life?

Have you dropped many of your activities and interests?
Do you feel that your life is empty?
Do you often get bored?
Are you in good spirits most of the time?
Are you afraid that something bad is going to happen to you?
Do you feel happy most of the time?
Do you often feel helpless?
Do you prefer to stay at home, rather than going out and doing new
things?
Do you feel you have more problems with memory than most?
Do you think it is wonderful to be alive now?
Do you feel pretty worthless the way you are now?
Do you feel full of energy?
Do you feel that your situation is hopeless?
Do you think that most people are better off than you are?

Sheikh et al. J Psychiatric Res 1983;17:37-49

Mini-Mental Status Examination

Folstein et al. 1975

1.

Educationally dependent

2.

Both false positives and false negatives

3.

Minimal testing of visuospatial system

SPIRITUAL ASSESMENT

10

01/06/2012

The Person

SOCIAL ASSESMENT

COMPONENT
The concept of God or deity (for exam-ple, Is
religion or God significant to you?)
Personal source of strength and hope (for example,
What is your source of strength and hope?)
Significance of religious practices and rituals (for
example, Are there any religious practices that
are important to you?)
Perceived relationship between spiritual belief and
health (for example, Has being sick made any
difference in your feelings about God or the
practice of your faith?)

Identified four questions that assess the

adequacy of social support
When you need help, can you count on
anyone for house cleaning, groceries, or
a ride?
Could you use more help with daily tasks?
Can you count on anyone for emotional
support (talking over problems or help-ing
you make a decision)?
Could you use more emotional help
(receiving sufficient support)?

11

01/06/2012

PRINCIPLES OF COMPREHENSIVE
ASSESSMENT

The cornerstone of an individualized plan of care for an older adult is a omprehensive assessment.
2. Comprehensive assessment takes into account age-related changes, age-associated diseases,
heredity, and lifestyle.
Nurses are members of the health care team, contributing to and drawing from the team to enhance the
assessment process.
Comprehensive assessment is not a neutral process.
Ideally, the older adult is the best source of information to assess his or her health.
When this is not possible, family members or caregivers are acceptable as secondary sources of
information. When the older adult cannot self-report, physical performance measures may provide
additional information.
Comprehensive assessment should first emphasize ability and then should address disability.
Appropriate interventions to maintain and enhance ability and to improve or compensate for disability
should follow from a comprehensive assessment.

SEKIAN

TERIMA KASIH

PRINCIPLES OF COMPREHENSIVE ASSESSMENT

Task performance and task capacity are two difference perspectives.
Some assessment tools ask Do you dress without help? (performance)
whereas others ask, Can you dress without help? (capacity).
Asking about capacity will result in answers that emphasize ability.
Assessment of older adults who have cognitive limitations may require
task segmenta-tion, or the breaking down of tasks into smaller steps.
Some assessment tools or parts of assessment tools may be more or
less applicable depending on the setting, that is, community, acute care,
or long-term care settings.
In comprehensive assessment, it is important to explore the meaning and
implications of health status from the older adults perspective. For
example, the same changes in visual acuity for two older adults may
have quite different meanings and implications for everyday life.

12