Pengkajian Gerontik Dibanjar

Program Studi Ilmu Keperawatan A Tahun 2017
ASUHAN KEPERAWATAN GERONTIK
Nama Mahasiswa : .......................................................

NIM : .......................................................
Alamat : .......................................................
Tanggal Pengkajian : .......................................................
Tanggal Praktek : .......................................................
A. PENGKAJIAN
1. IDENTITAS
a. Klien
Nama klien :
Tempat/tanggal lahir :
Umur :
Jenis kelamin :
Pendidikan terakhir :
Pekerjaan :
Alamat :
Diagnosa medis :
b. Penanggung Jawab
Nama klien :
Jenis kelamin :
Umur :
Pendidikan terakhir :
Pekerjaan :
Alamat :
2. KELUHAN UTAMA

Praktik Komunitas Keperawatan Gerontik

3. GENOGRAM
Keterangan Genogram:
: Laki-laki
: Perempuan
: Sudah Meninggal
: Tinggal Serumah
: Klien
4. RIWAYAT KESEHATAN


5. RIWAYAT KESEHATAN KELUARGA

6. RIWAYAT LINGKUNGAN HIDUP

7. RIWAYAT REKREASI

8. SUMBER/SISTEM PENDUKUNG YANG DIGUNAKAN

9. DESKRIPSI HARI KHUSUS


10. RIWAYAT KESEHATAN DAHULU

11. TINJAUAN SISTEM

(Jelaskan system-sistem di bawah ini yang terdapat pada klien dengan pedoman
Inspeksi, Palpasi, Perkusi, Auskultasi)
a. Keadaan Umum

b. Integumen

c. Kepala

d. Mata

e. Telinga



f. Hidung dan Sinus

g. Mulut dan Tenggorokan

h. Leher

i. Payudara

j. Pernapasan

k. Kardiovaskuler

l. Gastrointestinal

m. Perkemihan



n. Genitourinaria

o. Muskuloskletal

p. System Saraf Pusat

q. System Endokrin

r. Reproduksi

12. MASALAH KESEHATAN KRONIS

Isilah tanda rumput () untuk keluhan kesehatan yang dialami klien.
Keluhan Kesehatan atau Gejala yang Tidak

Selalu Sering Jarang
No Dirasakan Klien Dalam Waktu 3 Bulan Pernah
(3) (2) (1)
Terakhir Berkaitan Dengan Fungsi-Fungsi (0)
Fungsi Penglihatan
1. Penglihatan kabur
A
2. Mata berair
3. Nyeri pada mata
Fungsi Pendengaran
B 4. Pendengaran berkurang
5. Telinga berdenging
C Fungsi Paru (Pernafasan)
6. Batuk lama disertai keringat malam
7. Sesak nafas

8. Berdahak/sputum
Fungsi Jantung
9. Jantung berdebar-debar
D
10. Cepat lelah pada kaki/tangan
11. Nyeri dada
Fungsi Pencernaan
12. Mual/muntah
13. Nyeri ulu hati
E 14. Makan dan minum banyak
15. Perubahan kebiasaan BAB
(diare/konstipasi)
Fungsi Pergerakan
16. Nyeri kaki saat berjalan
F
17. Nyeri pinggang atau tulang belakang
18. Nyeri persendian/bengkak
Fungsi Persyarafan
19. Lumpuh/kelemahan
G 20. Kehilangan rasa
21. Gemetar/tremor
22. Nyeri/pegal pada daerah tengkuk
Fungsi Saluran Perkemihan
23. BAK banyak
H 24. Sering BAK pada malam hari
25. Tidak mampu mengontrol pengeluaran air
kemih (ngompol)
Jumlah
TOTAL
Skor:
25 = Masalah kesehatan kronis ringan
26-50 = Masalah kesehatan kronis sedang
51 = Masalah kesehatan kronis berat
INTERPRETASI HASIL PEMERIKSAAN: ......................................................................
13. PENGKAJIAN PSIKOSOSIAL DAN SPIRITUAL

a. Psikososial
Jelaskan kemampuan sosialisasi klien pada saat sekarang, sikap klien pada orang
lain, harapan- harapan klien dalam melakukan sosialisasi



b. Identifikasi Masalah Emosional
Pertanyaan tahap 1
(Tuliskanlah jawaban YA/TIDAK sesuai kondisi yang dialami klien)
Apakah klien mengalami kesulitan tidur (...)
Apakah klien sering merasa gelisah (...)
Apakah klien sering murung dan menangis sendiri (...)
Apakah klien sering was-was atau kuatir (...)
Lanjutkan ke pertanyaan tahap 2 jika lebih dari atau sama dengan 1 jawaban ya
Pertanyaan tahap 2
(Tuliskanlah jawaban YA/TIDAK sesuai kondisi yang dialami klien)
Keluhan lebih dari 3 bulan atau lebih dari 1 kali dalam 1 bulan? (...)
Ada atau banyak pikiran? (...)
Ada gangguan/masalah dengan keluarga lain? (...)
Menggunakan obat tidur/penenang atas anjuran dokter? (...)
Cenderung mengurung diri? (...)
Bila lebih dari atau sama dengan1 jawaban ya,
maka MASALAH EMOSIONAL POSITIF (+)
INTERPRETASI HASIL PEMERIKSAAN: ......................................................
c. Spiritual
(Kaji agama, kegiatan keagamaan, konsep/keyakinan klien tentang kematian,
harapan-harapan klien, dll)

14. PENGKAJIAN FUNGSIONAL KLIEN

a. INDEKS KATZ
Termasuk kategori manakah klien?

1. Mandiri dalam makan, kontinensia (BAB/BAK), menggunakan pakaian, pergi

ke toilet, berpindah dan mandi
2. Mandiri semuanya kecuali salah satu dari fungsi diatas
3. Mandiri kecuali mandi dan salah satu fungsi lain
4. Mandiri kecuali mandi, berpakaian dan salah satu fungsi diatas
5. Mandiri kecuali mandi, berpakaian, ke toilet dan salah satu fungsi yang lain
6. Mandiri kecuali mandi, berpakaian, ke toilet, berpindah dan satu fungsi yang
lain
7. Ketergantungan untuk semua fungsi diatas
Keterangan:
Mandiri berarti tanpa pengawasan, pengarahan atau bantuan efektif dari orang lain,
seseorang yang menolak untuk melakukan suatu fungsi dianggap tidak melakukan
fungsi, meskipun ia dianggap mampu.
INTERPRETASI: .....................................................................................................
b. MODIFIKASI DARI BARTHEL INDEKS

Termasuk yang manakah klien?
Dengan
No Kriteria Mandiri Keterangan
Bantuan
Frekuensi:
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Jumlah:
1 Makan 5 10 ...................................................
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Jenis:
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Frekuensi:
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Jumlah:
2 Minum 5 10 ...................................................
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Jenis:
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Berpindah dari kursi roda ...................................................
3 5-10 15 ...................................................
ketempat tidur/sebaliknya
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Frekuensi:
Personal toilet (cuci muka, ...................................................
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4 menyisir rambut, 0 5
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menggosok gigi) ...................................................
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Keluar masuk toilet ...................................................
5 (mencuci pakaian, menyeka 5 10 ...................................................
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tubuh, menyiram) ...................................................
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6 Mandi 5 15 ...................................................
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Frekuensi:
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7 Jalan di permukaan datar 0 5 ...................................................
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8 Naik turun tangga 5 10 ...................................................
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9 Menggunakan pakaian 5 10 ...................................................
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Frekuensi:
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10 Kontrol bowel (BAB) 5 10
Konsistensi:
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Frekuensi :
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11 Kontrol Bladder (BAK) 5 10
Warna :
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TOTAL SKOR
Keterangan:
110 : Mandiri
65-105 : Ketergantungan sebagian
60 : Ketergantungan total
INTERPRETASI: .....................................................................................................
15. PENGKAJIAN STATUS MENTAL GERONTIK

a. Identifikasi aspek kognitif dan fungsi mental dengan menggunakan MMSE (Mini
Mental Status Exam)
Nilai Nilai
No Aspek Kognitif Kriteria
Maksimal Klien
Menyebutkan dengan benar:
Tahun
Musim
1 ORIENTASI 5
Tanggal
Hari
Bulan
Dimana kita sekarang?
Negara Indonesia
Provinsi : ............................
2 ORIENTASI 5
Kota : ............................
Panti Wreda: ............................
Wisma : ............................
Sebutkan 3 obyek (oleh pemeriksa) 1 detik untuk
mengatakan masing masing obyek, kemudian
tanyakan kepada klien ketiga obyek tadi (untuk
3 REGISTRASI 3 disebutkan).
Obyek: ............................
Obyek: ............................
Obyek: ............................
4 PERHATIAN 5 Minta klien untuk memulai dari angka 100
DAN kemudian dikurangi 7 sampai 5 kali.

93
86
KALKULASI 79
72
65
Minta klien untuk mengulangi ketiga obyek pada
5 MENGINGAT 3 nomer 2 (registrasi) tadi, bila benar 1 point untuk
masing masing obyek.
1) Tunjukkan pada klien suatu benda dan
tanyakan namanya pada klien (misal jam
tangan atau pensil)
2) Minta kepada klien untuk mengulang kata

berikut tak ada, jika, dan, atau, tetapi bila
benar, nilai 2 point. Bila Pernyataan benar 2-3
buah, misal: tidak ada, tetapi maka nilai 1 point
3) Minta klien untuk mengikuti perintah berikut

yang terdiri dari 3 langkah: ambil kertas di
tangan anda, lipat dua dan taruh di lantai
6 BAHASA 9 Ambil kertas
Lipat dua
Taruh di lantai
4) Perintahkan pada klien untuk hal berikut (bila

aktivitas sesuai perintah nilai 1 point)
Tutup mata anda
5) Perintahkan pada klien untuk menulis satu

kalimat dan menyalin gambar
Tulis satu kalimat
Menyalin gambar
TOTAL NILAI

Penilaian:
> 23 : Aspek kognitif dari fungsi mental baik
18-22 : Kerusakan aspek fungsi mental ringan
17 : Terdapat kerusakan aspek fungsi mental berat
INTERPRETASI: .....................................................................................................
16. PENGOBATAN
No Tanggal Terapy (Nama, Waktu, Dosis, Rute)
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17. PEMERIKSAAN KHUSUS/DIAGNOSTIK LAINNYA

No Nama Pemeriksaan Tanggal Hasil Pemeriksa
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18. ANALISA DATA

Nama klien : ...................................................
Usia : ...................................................
Alamat : ...................................................
Tanggal : ...................................................
No Tanggal/Jam Data Fokus Masalah Penyebab
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19. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS

Diangnosa keperawatan yang mengacu pada klien lansia dan keluarga (diagnosa fisik/
biologis dan psikososial)
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20. RENCANA KEPERAWATAAN

Nama klien : ...................................................
Usia : ...................................................
Alamat : ...................................................
Tanggal : ...................................................
Diagnosa Nama/
No Tujuan dan Kriteria Hasil Intervensi Rasional
Keperawatan TTD
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21. CATATAN PERKEMBANGAN

Nama klien : ...................................................

Usia : ...................................................
Alamat : ...................................................
Tanggal : ...................................................
No Nama/
No Tanggal Jam Implementasi Respon Klien
Dx TTD
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22. EVALUASI
No Tanggal No Jam Evaluasi Nama/

Dx TTD
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23. DISCHARGE PLANNING (Pulang/Pindah Ruangan)

Dibuat dalam bentuk SOAPIE untuk pasien pulang atau pindah ruangan. Untuk S dan O dibuat dari hasil awal kajian, A sebagai diagnosa
yang ditemukan, P sebagai perancanaan yang akan dilakukan, I sebagai tindakan keperawatan yang telah dilakukan, dan E sebagai evaluasi
keadaan terakhir klien.
Discharge Planning
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S ....................................................................................................................................................................................................................
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O ....................................................................................................................................................................................................................
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A ....................................................................................................................................................................................................................
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P ....................................................................................................................................................................................................................
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I ....................................................................................................................................................................................................................
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Klien ...... L/P MRS pada tanggal .............. jam ... dengan diagnose medis ......................................... telah diberikan tindakan
keperawatan diatas. Untuk itu perlu perawatan lanjutan di .........................../kunjungan rutin ke ....................... mulai tanggal .........................
Terapi obat yang diberikan:

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Anjuran:

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Keterangan:
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Denpasar, ...........................................
Perawat
(..........)

Pengkajian Gerontik Dibanjar

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Pengkajian Gerontik Dibanjar

Diunggah oleh

Hak Cipta:

Format Tersedia

Program Studi Ilmu Keperawatan A Tahun 2017

ASUHAN KEPERAWATAN GERONTIK

Nama Mahasiswa : .......................................................

Praktik Komunitas Keperawatan Gerontik

Praktik Komunitas Keperawatan Gerontik

5. RIWAYAT KESEHATAN KELUARGA

6. RIWAYAT LINGKUNGAN HIDUP

8. SUMBER/SISTEM PENDUKUNG YANG DIGUNAKAN

9. DESKRIPSI HARI KHUSUS

Praktik Komunitas Keperawatan Gerontik

10. RIWAYAT KESEHATAN DAHULU

11. TINJAUAN SISTEM

Praktik Komunitas Keperawatan Gerontik

Praktik Komunitas Keperawatan Gerontik

12. MASALAH KESEHATAN KRONIS

Keluhan Kesehatan atau Gejala yang Tidak

Praktik Komunitas Keperawatan Gerontik

13. PENGKAJIAN PSIKOSOSIAL DAN SPIRITUAL

Praktik Komunitas Keperawatan Gerontik

14. PENGKAJIAN FUNGSIONAL KLIEN

Praktik Komunitas Keperawatan Gerontik

1. Mandiri dalam makan, kontinensia (BAB/BAK), menggunakan pakaian, pergi

b. MODIFIKASI DARI BARTHEL INDEKS

Praktik Komunitas Keperawatan Gerontik

Praktik Komunitas Keperawatan Gerontik

15. PENGKAJIAN STATUS MENTAL GERONTIK

Praktik Komunitas Keperawatan Gerontik

2) Minta kepada klien untuk mengulang kata

3) Minta klien untuk mengikuti perintah berikut

4) Perintahkan pada klien untuk hal berikut (bila

5) Perintahkan pada klien untuk menulis satu

Praktik Komunitas Keperawatan Gerontik

17. PEMERIKSAAN KHUSUS/DIAGNOSTIK LAINNYA

Praktik Komunitas Keperawatan Gerontik

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Praktik Komunitas Keperawatan Gerontik

18. ANALISA DATA

Praktik Komunitas Keperawatan Gerontik

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Praktik Komunitas Keperawatan Gerontik

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Praktik Komunitas Keperawatan Gerontik

19. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS

Praktik Komunitas Keperawatan Gerontik

20. RENCANA KEPERAWATAAN

Praktik Komunitas Keperawatan Gerontik

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Praktik Komunitas Keperawatan Gerontik

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Praktik Komunitas Keperawatan Gerontik

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Praktik Komunitas Keperawatan Gerontik

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Praktik Komunitas Keperawatan Gerontik

Nama klien : ...................................................

Praktik Komunitas Keperawatan Gerontik

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Praktik Komunitas Keperawatan Gerontik

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Praktik Komunitas Keperawatan Gerontik

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Praktik Komunitas Keperawatan Gerontik

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