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Form penilaian logbook

Aspek 1 2 3
Capaian pembelajaran psikomotor
Mendemonstrasikan proses pembelajaran
Kreatifitas
Menunjukan proses berpikir kritis
Interpretasi dan analisa
Ketepatan waktu penyerahan
Ket: 3: sangat baik; 2: baik; 1: kurang baik

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Form Penilaian Portofolio
Aspek 1 2 3
Relevansi dengan capaian pembelajaran
Originalitas (keaslian tulisan)
Mendemonstrasikan proses pembelajaran
Kreatifitas
Menunjukan proses berpikir kritis
berfokus pada pemmecahan masalah
Interpretasi dan analisa
Ketepatan waktu penyerahan
Ket: 3: sangat baik; 2: baik; 1: kurang baik

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Format penilaian SOCA
Aspek 1 2 3
Menggambarkan gejala secara akurat
Menetapkan keluhan utama
Menyampaikan hasil pengkajian (pengkajian khusus lanjut usia) secara detail
terutama pada masalah yang penting

Menyampaikan fakta terkait untuk pendukung diagnosa


Menyampaikan masalah berdasarkan prioritas
Berbicara jelas
Menggunakan terminology yang tepat
Menyampaikan dampak penyakit pada pasien
Menyampaikan riwayat psikososial
Menyampaikan hasil pemeriksaan fisik dan kajian sistem tubuh
Struktur penyampaian jelas
Tujuan dan penetapan rencana
Ket: 3: sangat baik; 2: baik; 1: kurang baik

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FORMAT PENILAIAN DISKUSI REFLEKSI KASUS

Skor
No KEGIATAN BBT
Nilai

A PENGKAJIAN 100%
1. Ketepatan penggunaan alat pengkajian 30
2. Ketrampilan pengambilan data 30
3. Validitas data 20
4. Kelengkapan data kajian (data focus) 20
B PERUMUSAN DIAGNOSA 100%
1. Ketepatan pengelompokan data 25
2. Ketepatan menganalisa data 50
3. Ketepatan rumusan diagnosa 25
keperawatan
C PERENCANAAN 100%
1. Ketepatan penyusunan prioritas dx 25
2. Ketepatan tujuan dan criteria hasil 35
3. Relevansi rencana tindakan dg diagnosa kep 40
D PELAKSANAAN 100%
1. Kemampuan mengelola pelaksanaan tindakan 35
2. Kemampuan kolaborasi dg tim kes 20
3. Kemampuanmelibatkan klien & klg 20
4. Mendokumentasikan tindakan dengan benar 25
E EVALUASI 100%
1. Kualitas isi perkembangan klien :
a. subjektif, objektif sesuai criteria hasil 20
b. ketajaman analisa data 25
c. tindak lanjut & modifikasi 15
2. Validitas proses evaluasi 20
3. Penampilan klien setelah dirawat 20

Penilai

A = 80 100
AB = 75-79,99
B = 70 74,99
< 70 Tidak Lulus

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Lampiran 1. Format Pengkajian Individu Lansia

FORMAT PENGKAJIAN INDIVIDU LANSIA

Penting untuk memahami rasionalisasi/ latar belakang dari setiap pertanyaan yang diajukan
(Mengapa kita ingin mendapatkan informasi berkaitan dengan hal tersebut)!

I. IDENTITAS
A. Nama :
B. Jenis Kelamin :
C. Umur :
D. Agama :
E. Status Perkawinan :
F. Pendidikan Terakhir :
G. Pekerjaan saat ini/ sebelumnya :
H. Asal/ Tempat tinggal sebelumnya :
I. Tanggal Pengkajian :

II. KELUHAN UTAMA (apa yang dirasakan/ dikeluhkan klien saat pengkajian?)
III. RIWAYAT KESEHATAN SAAT INI (berfokus untuk mengkaji lebih lanjut keluhan
utama)
Kaji!
Hal-hal apa yang menyebabkan/ meningkatkan/ menurunkan keluhan (P/
Provokative & palliative)?
Kualitasnya/ gambarannya seperti apa (Q/ Quality)?
Terjadinya di daerah mana (R/ Regio)?
Seberapa parah? Efek/ akibat dari keluhan utama terhadap hidup klien sehari-hari
(S/ Severity)?
Mulai kapan/ seberapa sering muncul/ ritme/ durasi (T/ Time)?
Apa saja yang klien telah lakukan untuk mengatasinya? Bagaimana hasilnya?
(PQRST tidak hanya bisa digunakan pada keluhan nyeri, tapi juga pada keluhan yang lain
dengan penyesuaian, sebagai contoh pusing, sesak dsb)

IV. RIWAYAT KESEHATAN TERDAHULU (berfokus untuk mengkaji masalah selain


keluhan utama)
Kaji!
Riwayat operasi,
Riwayat hospitalisasi,
Riwayat penyakit terdahulu (yang tediagnosa oleh dokter ataupun tidak)
Riwayat pengobatan,
Penyakit kronis yang diderita
Riwayat alergi (terhadap makanan atau obat-obatan)

V. PENGKAJIAN KEPERAWATAN 11 POLA FUNGSIONAL GORDON


A. HEALTH PROMOTION & MANAGEMENT
Kaji!
Kebiasaan kesehatan yang dijalani klien (ex. OR, merokok, alkohol dsb);
Manajemen penyakit yang diderita (termasuk obat-obatan; kepatuhan terhadap
saran dokter/perawat);
Perilaku pencarian pelayanan kesehatan

B. NUTRITION
Kaji!
Kualitas (jenis) & kuantitas (jumlah) asupan makanan?
Kualitas (jenis) & kuantitas (jumlah) asupan cairan (minuman)?
Penggunaan suplement/ vitamin?
BB-TB (hitung IMT?), riwayat penurunan/ kenaikan BB yang signifikan?
Lab (Albumin, Hb, jika ada)?
Nafsu makan, kesulitan mengunyah/ menelan?
Diet khusus yang dijalani?
Lengkapi hasil pengkajian fisik sistem gastrointestinal, sistem integument,
sistem endokrin, riwayat penyakit (DM?)
Screening malnutrition? lihat file assessment determineNutrition

C. ELIMINATION (Fungsi urinary & bowel (BAK & BAB)


Kuantitas (frekuensi, jumlah);
Kualitas (warna, konsistensi, bau);
Pengaturan (volunter/ involunter), inkontinensia? Bisa gunakan bladder diary
lihat file assessment BladerDiary
Lihat hasil pengkajian fisik sistem gastrointestinal, sistem urinary, riwayat
penyakit/ operasi (BPH?)

D. ACTIVITY & EXERCISE


Kaji!
Kemampuan fungsional: ADL Katz Index/ Barthel Index; IADL Lawton-
Brody Scale (Form pengkajian ADL-IADL lihat file assessment Katz
ADL_Lawton IADL
Olah raga
Aktivitas rekreasional (aktivitas di waktu senjang)
Level mobilitas lihat hasil pengkajian sistem muskuloskeletal (osteoporosis,
rheumatoid?), sistem neurologi (stroke?)
Cara berjalan (gait), posture, keseimbangan lihat hasil pengkajian sistem
muskuloskeletal (osteoporosis, rheumatoid?), sistem neurologi (stroke?)
Resiko jatuh? Screening resiko jatuh lihat file assessment
TinnettiBalanceAsessment
Respon kardiovaskular ketika beraktivitas lihat hasil pengkajian sistem
kardiovaskular (CHF?)
Keseimbangan energi
Pada klien yang bed-rest, dapat dikaji resiko untuk mengalami pressure ulcer.
Screening resiko lihat file assessment bradenScale

E. SLEEP
Kualitas & kuantitas tidur (siang/ malam), lingkungan tidur, penyakit/ kondisi
yang mungkin mempengaruhi
Problem tidur?
Kaji secara detail kemungkinan penyebab agar dapat menentukan intervensi yang
sesuai

F. PERSEPSI-SENSORI & KOGNISI


Orientasi & fungsi kognitif?
Screening gangguan fungsi kognitif lihat file assessment MMSQ (Lihat
dan gunakan form di hal 1 dari file ini) dan Clock drawing
Fungsi sensorik, adakah gangguan pada sistem sensorinya? lihat fungsi sistem
sensori (gangguan penglihatan, pendengaran??); sistem neurologi (stroke?)
Fungsi komunikasi, adakah gangguan komunikasi lihat fungsi sistem sensori
(pendengaran??); sistem neurologi (stroke?)
Screening fungsi penglihatan lihat file assessment SnellenChart
Screening fungsi pendengaran lihat file assessment whisperedVoice

G. KONSEP DIRI
Berkaitan dengan aspek psikologis klien
Kaji pandangan atau penilaian terhadap diri, meliputi harga diri, citra tubuh, peran
dan identitas diri
Observasi selama wawancara: kontak mata, suara dan pola bicara, ketegangan
Screening depresi pada lansia Screening: Geriatric Depression Scale (GDS)
lihat file assessment GDS.

H. POLA HUBUNGAN
Kajj hubungan dengan pasangan, keluarga, teman, masyarakat sekitar
Penampilan peran (ex. peran sebagai suami/ istri; peran sebagai
orangtua/kakek/nenek; peran sebagai teman, peran sebagai tetua di masyarakat)
Lansia sering juga berperan sebagai caregiver (pemberi perawatan) terhadap
pasangannya yang sakit

I. SEKSUALITAS
Bukan untuk tujuan reproduksi
Seringkali lansia enggan untuk membicarakannya. Tanyakan apakah ada hal yang
ingin didiskusikan berkaitan dengan fungsi seksualitasnya!
Kaji apakah klien masih aktif secara seksual? Penyakit/ kondisi yang
mempengaruhi seksualitas klien (DM, CHF?)

J. POLA KOPING-TOLERANSI TERHADAP STRESS


Kemampuan individu untuk menghadapi stressor
Identifikasi stressor/problem yang dihadapi klien saat ini!
Kaji bagaimana klien menghadapi masalah di waktu lampu! Bagaimana
keefektivannya?
Kaji support system yang tersedia

K. POLA NILAI-KEYAKINAN (SPIRITUALITAS)


Sesuatu hal yang diyakini dan dihayati individu dan menjadi pendorong untuk
bertindak
Kaji!
Nilai & keyakinan yang dianut klien berkaitan dengan sehat-sakit, hidup-mati
Praktek keagamaan yang terkait
Rencana klien untuk masa depan

VI. PEMERIKSAAN FISIK


A. PENAMPILAN UMUM (Jelaskan seperti apa keadaan umum klien!)
B. TANDA-TANDA VITAL (Kesadaran, Suhu, Nadi, TD, RR, TB, BB)
C. PEMERIKSAAN FISIK (Bisa menggunakan pendekatan Head-to-Toe atau
pendekatan per Sistem)

V. INFORMASI PENUNJANG
A. DIAGNOSA MEDIS (Apabila tersedia)
B. LABORATORIUM (Apabila tersedia)
C. TERAPI MEDIS (Cek obat-obatan yang dikonsumsi klien! Terkadang kita bisa
mengidentifikasi obat dari kemasannya)

Note:
Jika anda melakukan pemeriksaan screening, maka pada format pengkajian, cukup tuliskan
hasil/ kesimpulannya saja. Namun, tetap sertakan form screening yang telah diisi sebagai
lampiran.

Anda mungkin akan mendapati klien lansia di unit rehabilitasi sosial yang mengalami
gangguan komprehensi (pemahaman) ataupun komunikasi. Maka sesuaikan penggunaan
form pengkajian individu ini dengan memfokuskan pada hal-hal yang bisa anda amati atau
observasi (objektif), dibandingkan dengan data subyektif!
Lampiran 2. Format Pengkajian Kelompok

FORMAT PENGKAJIAN KELOMPOK

I. IDENTITAS KELOMPOK

Nama Kelompok :
Alamat :
Anggota :

II. PROFIL KELOMPOK

A. PROFIL (DIMENSI) BIOLOGIS


Jelaskan keadaan biologis para anggota kelompok!

B. PROFIL (DIMENSI) PSIKOLOGIS


Jelaskan situasi psikologis kelompok! Apakah yang sering menjadi stressor bagi kelompok! Bagaimana
koping kelompok!

C. PROFIL (DIMENSI) LINGKUNGAN FISIK


Jelaskan keadaan lingkungan fisik dimana kelompok tersebut berada!

D. PROFIL (DIMENSI) LINGKUNGAN SOSIAL


Jelaskan keadaan lingkungan sosial dimana kelompok tersebut berada!

E. DIMENSI PERILAKU (KESEHATAN DAN SOSIAL)


Jelaskan bagaimana perilaku kesehatan kelompok! Bagaimana interaksi diantara anggota kelompok?
Bagaimana interaksi kelompok dengan kelompok yang lain?

Note:
Lakukan pengkajian individu lansia terlebih dahulu untuk kemudian baru menyimpulkan keadaan kelompok.

Hasil pengkajian tersebut menjadi dasar anda untuk menentukan intervensi terapi modalitas/ aktivitas
kelompok!
1) Pengkajian Fungsional ADL dan IADL
Index of Independence in Activities of Daily Living
(Katz Index of ADL)

Patients Name: Date:

Instructions: For each area of functioning listed below, check the description that applies. (The word "assistance" means supervision, direction, or personal
assistance.) Data recorded on the evaluation form is converted into an overall ADL grade with the aid of definitions in the table on the following page.
BATHING either sponge bath, tub bath, or shower
Bathing self without assistance Receives assistance in bathing only one part of the Receives assistance in bathing more than one part of
body (such as back or a leg) the body (or not bathed)
DRESSING gets clothes from closets and drawers including underclothes, outer garments, and using fasteners (including braces, if worn)
Gets clothes and gets completely dressed without Gets clothes and gets dressed without assistance Receives assistance in getting clothes or in getting
assistance) except for assistance in tying shoes dressed, or stays partly or completely undressed
TOILETING going to the "toilet room" for bowel and urine elimination, cleaning self after elimination, and arranging clothes
Goes to "toilet room," cleans self, and arranges clothes Receives assistance in going to "toilet room" or in Doesn't go to room termed "toilet" for the elimination
without assistance (may use object for support such as cleaning self or in arranging clothes after elimination process
cane, walker, or wheelchair and may manage night or in use of night bedpan or commode
bedpan or commode, emptying same in morning)
TRANSFER
Moves in and out of bed as well as in and out of chair Moves in and out of bed or chair with assistance Doesn't get out of bed
without assistance (may be using object for support
such as cane or walker)
CONTINENCE
Controls urination and bowel movement completely by Has occasional "accidents" Supervision helps keep urine or bowel control, catheter
self is used, or is incontinent
FEEDING
Feeds self without assistance Feeds self except for getting assistance in cutting meat Receives assistance in feeding or is fed partly or
or buttering bread completely by using tubes or intravenous fluids
Sources: Katz S, Downs TD, Cash HR, Grotz RC. (197). Progress in development of the index of ADL. Gerontologist, 10(1):20-30.
Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. (1963). Studies of illness in the aged. The Index of ADL: a standardized measure of biological
and psychosocial function. JAMA,185(12):914-9

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Scoring:
The Index of Independence in Activities of Daily Living is based on an evaluation of the functional independence or dependence of patients in bathing,
dressing, toileting, transferring, continence, and feeding. Specific definitions of functional independence and dependence appear below the index.
A Independent in feeding, continence, transferring, toileting, dressing, and bathing
B Independent in all but one of these functions
C Independent in all but bathing and one additional function
D Independent in all but bathing, dressing, and one additional function
E Independent in all but bathing, dressing, toileting, and one additional function
F Independent in all but bathing, dressing, toileting, transferring, and one additional function
G Dependent in all six functions
Other Dependent in at least two functions, but not classifiable as C, D, E, or F.
Definition
Independence means without supervision, direction, or active personal assistance, except as specifically noted below. This is based on actual status and not on
ability. A patient who refuses to perform a function is considered as not performing the function, even though he or she is deemed able.
Independent Dependent
Bathing (sponge, Assistance only in bathing a single part (as back or disabled Assistance in bathing more than just one part of body, assistance in
shower, or tub) extremity) or bathes self completely getting in or out of tub, or does not bathe self
Dressing Gets clothes from closets and drawers; puts on clothes, outer Does not dress self or remains partly undressed
garments, braces; manages fasteners; act of tying shoes is excluded
Toileting Gets to toilet, gets on and off toilet, arranges clothes, cleans organs Uses bedpan or commode or receives assistance in getting to and
of excretion (may manage own bedpan used at night only and may using toilet
not be using mechanical supports)
Transfer Moves in and out of bed independently and moves in and out of Assistance in moving in or out of bed and/or chair; does not
chair independently (may or may not be using mechanical supports) perform one or more transfers
Continence Urination and defecation entirely self-controlled Partial or total incontinence in urination or defecation; partial or
total control by enemas, catheters, or regulated use of urinals
and/or bedpans
Feeding Gets food from plate or its equivalent into mouth (precutting of meat Assistance in act of feeding (see above); does not eat at all or
and preparation of food, as buttering bread, are excluded from parenteral feeding
evaluation)

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Source: try this: Best Practices in Nursing Care to Older Adults, The Hartford Institute for Geriatric Nursing, New York University, College of Nursing,
www.hartfordign.org. University College of Nursing
LAWTON-BRODY
INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE (I.A.D.L.)
Scoring: For each category, circle the item description that most closely resembles the
clients highest functional level (either 0 or 1).
A. Ability to Use Telephone E. Laundry
1. Operates telephone on own initiative-looks up and 1 1. Does personal laundry completely 1
dials numbers, etc.
2. Dials a few well-known numbers 1 2. Launders small items-rinses stockings, etc. 1
3. Answers telephone but does not dial 1 3. All laundry must be done by others 0
4. Does not use telephone at all 0
B. Shopping F. Mode of Transportation
1. Takes care of all shopping needs independently 1 1. Travels independently on public 1
transportation or drives own car
2. Shops independently for small purchases 0 2. Arranges own travel via taxi, but does not 1
otherwise use public transportation
3. Needs to be accompanied on any shopping trip 0 3. Travels on public transportation when 1
accompanied by another
4. Completely unable to shop 0 4. Travel limited to taxi or automobile with 0
assistance of another
5. Does not travel at all 0
C. Food Preparation G. Responsibility for Own Medications
1. Plans, prepares and serves adequate meals 1 1. Is responsible for taking medication in 1
independently correct dosages at correct time
2. Prepares adequate meals if supplied with ingredients 0 2. Takes responsibility if medication is 0
prepared in advance in separate dosage
3. Heats, serves and prepares meals, or prepares meals, 0 3. Is not capable of dispensing own medication 0
or prepares meals but does not maintain adequate diet
4. Needs to have meals prepared and served 0
D. Housekeeping H. Ability to Handle Finances
1. Maintains house alone or with occasional assistance 1 1. Manages financial matters independently 1
(e.g. "heavy work domestic help") (budgets, writes checks, pays rent, bills, goes
to bank), collects and keeps track of income

2. Performs light daily tasks such as dish washing, bed 1 2. Manages day-to-day purchases, but needs 1
making help with banking, major purchases, etc.
3. Performs light daily tasks but cannot maintain 1 3. Incapable of handling money 0
acceptable level of cleanliness
4. Needs help with all home maintenance tasks 1
5. Does not participate in any 0
Total score: ________________________
A summary score ranges from 0 (low function, dependent) to 8 (high function, independent) for women and 0
through 5 for men to avoid potential gender bias.

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2) Pengkajian Resiko Jatuh

TINETTI BALANCE ASSESSMENT TOOL

Tinetti ME, Williams TF, Mayewski R, Fall Risk Index for elderly patients based on number of chronic dis-
abilities. Am J Med 1986:80:429-434

PATIENTS NAME ______________________D.o.b.___________________ Ward _________________

BALANCE SECTION
Patient is seated in hard, armless chair;

Date

Sitting Balance Leans or slides in chair = 0


Steady, safe = 1

Unable to without help = 0


Rises from chair Able, uses arms to help = 1
Able without use of arms = 2

Unable to without help = 0


Attempts to rise Able, requires > 1 attempt = 1
Able to rise, 1 attempt = 2

Immediate standing Unsteady (staggers, moves feet, trunk sway) = 0


Balance (first 5 seconds) Steady but uses walker or other support = 1
Steady without walker or other support = 2

Unsteady = 0
Standing balance Steady but wide stance and uses support = 1
Narrow stance without support = 2

Begins to fall = 0
Nudged Staggers, grabs, catches self = 1
Steady = 2

Eyes closed Unsteady = 0


Steady = 1
Discontinuous steps = 0
Continuous = 1
Turning 360 degrees
Unsteady (grabs, staggers) = 0
Steady = 1
Unsafe (misjudged distance, falls into chair) = 0
Sitting down Uses arms or not a smooth motion = 1
Safe, smooth motion = 2

Balance score /16 /16

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TINETTI BALANCE ASSESSMENT TOOL

GAIT SECTION

Patient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace.

Date
Indication of gait Any hesitancy or multiple attempts = 0
(Immediately after told No hesitancy = 1
to go.)
Step to = 0
Step length and height Step through R = 1
Step through L = 1
Foot drop = 0
Foot clearance L foot clears floor = 1
R foot clears floor = 1

Step symmetry Right and left step length not equal = 0


Right and left step length appear equal = 1

Step continuity Stopping or discontinuity between steps = 0


Steps appear continuous = 1

Marked deviation = 0
Path Mild/moderate deviation or uses w. aid = 1
Straight without w. aid = 2

Marked sway or uses w. aid = 0


Trunk No sway but flex. knees or back or
uses arms for stability = 1
No sway, flex., use of arms or with aid = 2

Walking time Heels apart = 0


Heels almost touching while walking = 1
Gait score /12 /12

Balance score carried forward /16 /16

Total Score = Balance + Gait score /28 /28

Risk Indicators:
Tinetti Tool Score Risk of Falls
18 High
19-23 Moderate
24 Low

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3) Pengkajian Fungsi Kognitif

MINI MENTAL STATE EXAMINATION (MMSE)


Name: _________________ Date: __________________ Examiner: __________________
SCORE
(Circle
one)
ORIENTATION
1.What is the year? 0 1
2.What is the season? (allow for error if beginning/end of season) 0 1
3.What month is it now? (allow for error if first/last day of month) 0 1
4.What day of the week is it today? (allow for error if near midnight) 0 1
5.What is todays date? 0 1
6.What country are we in now? 0 1
7.What city/town are we in? (if rural, ask what province) 0 1
8.What suburb are we in? (if rural, ask what area/district) 0 1
9.What building/place are we in? (name or type) 0 1
10.What Ward/floor/room of the building/place are we in? 0 1
*Score 1 point for correct response, maximum 10.

REGISTRATION
Listen carefully. Im going to say three words.
You say them back when Ive finished. Ready? (present 1 second each):
*(Read this way tick which items used)
1st trial APPLE COIN CHAIR 0 1/2/3
re-test BALL CAR MAN
2nd re-test SHOE FLAG TREE
*Repeat up to 5 times (until patient can repeat all 3), but score only first trial.
Number of trials: ........
Now keep those words in mind. Im going to ask you to say them again in a few minutes

ATTENTION AND CALCULATION [Serial 7s]


Now Id like you to subtract 7 from 100. Then keep subtracting 7 from each answer until I tell 0 1
you to stop. What is 100 take away 7? 0 1
0 1
*(If needed say, keep going. Score 1 point for each answer that is 7 less than the previous 0 1
number. Maximum 5) 0 1
*Dont remind patient of where they are up to. If they lose track, say something like, Give
your best guess.
*If patient refuses to perform serial 7s or is clearly unable to, substitute WORLD item below.
Spell WORLD forward (correct any misspelling), then backward (score backward spelling - 1
point for each letter that appears in the correct order)

RECALL
What were those three words I asked you to remember?
1. _________________ 0
2. _________________ 1
3. _________________ 2
*Score 1 point for each correct item, maximum 3. Do not prompt but if no response, say Take 3
a moment or Take a guess.

NAMING
15
What is this? (Point to a pen or pencil) 0 1
What is this? (Point to a watch) 0 1

*Alternative common objects (e.g., glasses, chair, and keys) can be used.
1 point each for correct name of whole, or part of, objects

REPETITION
Listen carefully, I am going to ask you to repeat what I say. Ready? 0 1
THE PASTRY COOK WAS ELATED. Now you say that.

*Alternative item: NO IFS, ANDS, OR BUTS.


*Repeat up to 5 times, but score only first trial. Number of trials: .........

COMPREHENSION
Listen carefully because Im going to ask you to do something
*(Present piece of paper to patient's midline ONLY after giving complete instruction )
Take this piece of paper in your right/left (non-dominant) hand 0 1
Fold it in half 0 1
And put it on the floor 0 1

READING
Please read this and do what it say (use separate page) 0 1
CLOSE YOUR EYES

WRITING
Please write me a sentence (use separate page) 0 1
*If person doesnt respond, say, Write about the weather. (Cue used: yes/no) The sentence
must contain a subject, verb and make sense. Ignore grammar or spelling.

DRAWING
Please copy this design. (use separate page) 0 1
*Score 1 point if drawing consists of two 5-sided figures that intersect to form a 4-sided figure

TOTAL SCORE

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Clock Drawing Test

Patients Name: Date:

17
Instructions for the Clock Drawing Test:
Step 1: Give patient a sheet of paper with a large (relative to the size of handwritten numbers)
predrawn circle on it. Indicate the top of the page.
Step 2: Instruct patient to draw numbers in the circle to make the circle look like the face of a clock
and then draw the hands of the clock to read "10 after 11."

Scoring:
Score the clock based on the following six-point scoring system:

Score Error(s) Examples


1 "Perfect" No errors in the task
2 Minor visuospatial errors a) Mildly impaired spacing of times
b) Draws times outside circle
c) Turns page while writing so that some
numbers appear upside down
d) Draws in lines (spokes) to orient spacing
3 Inaccurate representation of 10 after 11 when a) Minute hand points to 10
visuospatial organization is perfect or shows b) Writes "10 after 11"
only minor deviations c) Unable to make any denotation of time

4 Moderate visuospatial disorganization of a) Moderately poor spacing


times such that accurate denotation of 10 after b) Omits numbers
11 is impossible c) Perseveration: repeats circle or continues on
past 12 to 13, 14, 15, etc.
d) Right-left reversal: numbers drawn
counterclockwise
e) Dysgraphia: unable to write numbers
accurately
5 Severe level of disorganization as See examples for scoring of 4
described in scoring of 4
6 No reasonable representation of a clock a) No attempt at all
b) No semblance of a clock at all
c) Writes a word or name
(Shulman et al., 1993)

Higher scores reflect a greater number of errors and more impairment. A score of 3 represents a cognitive
deficit, while a score of 1 or 2 is considered normal.

Sources:
Kirby M, Denihan A, Bruce I, Coakley D, Lawlor BA. The clock drawing test in primary care:
sensitivity in dementia detection and specificity against normal and depressed elderly. Int J Geriatr
Psychiatry. 2001;16:935-940.
Richardson HE, Glass JN. A comparison of scoring protocols on the clock drawing test in relation
to ease of use, diagnostic group, and correlations with Mini-Mental State Examination. J Am
Geriatr Soc. 2002;50:169-173.
Shulman KI, Gold DP, Cohen CA, Zucchero CA. Clock drawing and dementia in the
community: a longitudinal study. Int J Geriatr Psychiatry. 1993;8:487-496.

18
4) Screening resiko masalah nutrisi

DETERMINE YOUR NUTRITIONAL HEALTH


The Warning Signs of poor nutritional health are often overlooked. Use this Checklist to find
out if you or someone you know is at nutritional risk.

Read the statements below. Circle the number in the yes column for those that apply to you
or someone you know. For each yes answer, score the number in the box. Total your
nutritional score

YES
I have an illness or condition that made me change the kind and/or amount of 2
food
I eat fewer than 2 meals per day. 3
I eat few fruits or vegetables or milk products. 2
I have 3 or more drinks of beer, liquor or wine almost every day. 2
I have tooth or mouth problems that make it hard for me to eat 2
I dont always have enough money to buy the food I need. 4
I eat alone most of the time 1
I take 3 or more different prescribed or over-the-counter drugs a day 1
Without wanting to, I have lost or gained 10 pounds in the last 6 months 2
I am not always physically able to shop, cook, and/or feed my-self 2
Total

Total Your Nutritional Score. If its


0-2 = Good! Recheck your nutritional score in 6 months.
3-5 = You are at moderate nutritional risk.
See what can be done to improve your eating habits and lifestyle. Your office on aging,
senior nutrition program, senior citizens center or health department can help. Recheck
your nutritional score in 3 months.
6 or more = You are at high nutritional risk.

Bring this Checklist the next time you see your doctor, dietitian or other qualified health or
social service professional. Talk with them about any problems you may have. Ask for help to
improve your nutritional health.

Remember that Warning Signs suggest risk, but do not represent a diagnosis of any
condition. Turn the page to learn more about the Warnings Signs of poor nutritional
health.

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The Nutrition Checklist is based on the Warning Signs described below.
Use the word DETERMINE to remind you of the Warning Signs.

DISEASE
Any disease, illness or chronic condition which causes you to change the way you eat, or makes it hard for
you to eat, puts your nutritional health at risk. Four out of five adults have chronic diseases that are affected
by diet. Confusion or memory loss that keeps getting worse is estimated to affect one out of five or more of
older adults. This can make it hard to remember what, when or if youve eaten. Feeling sad or depressed,
which happens to about one in eight older adults, can cause big changes in appetite, digestion, energy level,
weight and well-being.
EATING POORLY
Eating too little and eating too much both lead to poor health. Eating the same foods day after day or not
eating fruit, vegetables, and milk products daily will also cause poor nutritional health. One in five adults skip
meals daily. Only 13% of adults eat the minimum amount of fruit and vegetables needed. One in four older
adults drink too much alcohol. Many health problems become worse if you drink more than one or two
alcoholic beverages per day.
TOOTH LOSS/MOUTH PAIN
A healthy mouth, teeth and gums are needed to eat. Missing, loose or rotten teeth or dentures which dont fit
well, or cause mouth sores, make it hard to eat.

ECONOMIC HARDSHIP
As many as 40% of older Americans have incomes of less than $6,000 per year. Having less -- or
choosing to spend less -- than $25-30 per week for food makes it very hard to get the foods you
need to stay healthy.

REDUCED SOCIAL CONTACT


One-third of all older people live alone. Being with people daily has a positive effect on morale,
well-being and eating.

MULTIPLE MEDICINES
Many older Americans must take medicines for health problems. Almost half of older Americans
take multiple medicines daily. Growing old may change the way we respond to drugs. The more
medicines you take, the greater the chance for side effects such as increased or decreased appetite, change in
taste, constipation, weakness, drowsiness, diarrhea, nausea, and others. Vitamins or minerals, when taken in
large doses, act like drugs and can cause harm. Alert your doctor to everything you take.

INVOLUNTARY WEIGHT LOSS/GAIN


Losing or gaining a lot of weight when you are not trying to do so is an important warning sign that must
not be ignored. Being overweight or underweight also increases your chance of poor health.

NEEDS ASSISTANCE IN SELF CARE


Although most older people are able to eat, one of every five have trouble walking, shopping,
buying and cooking food, especially as they get older.

ELDER YEARS ABOVE AGE 80


Most older people lead full and productive lives. But as age increases, risk of frailty and health
problems increase. Checking your nutritional health regularly makes good sense.

20
NAME DATE
5) Pengkajian Pola Berkemih/ Resiko Inkontinensia

URINARY DIARY

TIME URINATE IN LEAKING REASON FOR ACCIDENT


TOILET ACCIDENT

6 a.m.
7 a.m.
8 a.m.
9 a.m.
10 a.m.
11 a.m.
12 Noon
1 p.m.
2 p.m.
3 p.m.
4 p.m.
5 p.m.
6 p.m.
7 p.m.
8 p.m.
9 p.m.
10 p.m.
11 p.m.
12 mid
1 a.m.
2 a.m.
3 a.m.
4 a.m.
5 a.m.

21
NAME DATE
INSTRUCTIONS

1. In the 1st column, make a checkmark in the box next to the time when you urinate into the toilet.
You may need to put more than one in the box if you urinate more than once in an hour.

2. In the 2nd column, mark a checkmark in the box close to the time of each urine leak (accident.)
Record leaks of any amount. Make as many checkmarks as leaks in that hour.

3. If an accident occurred, indicate the reason or circumstances surrounding the accident, for
example, coughed, or bent over, or sudden urge, or dont know why I leaked.

4. Circle the time when you got up in the morning and when you went to bed.

5. Use the space below to record the number and types of pads you use or make any other notes you
think might be helpful in understanding your bladder problems.

Janis Luft, NP
UCSF Womens Continence Center 8/30/01

22
6) Pengkajian Fungsi Pendengaran

Whispered Voice Test

Performing the Whispered Voice Test:


1. Stand behind the patients field of vision. This eliminates the possibility of lip-reading.
2. Gently occlude and rub the external auditory canal of the non-tested ear.
3. Ask the patient to repeat a set of 3 different random numbers (e.g., 6,1,9) presented to the tested ear at
four decreasing levels of loudness: conversational voice at 6 inches and at 2 feet from the ear, and
whispered voice at 6 inches and at 2 feet from the ear. Exhale completely prior to testing with
whispered voice.

Scoring:
A passing score is given if the patient can repeat all three numbers correctly at each level of loudness
or achieve greater than 50% success over three successive triplet sets.

Failure to pass at each level of voice testing is considered a positive test for hearing impairment. Failure to
hear a whisper at 2 feet indicates hearing loss and may be the most discriminant test of the set.

Source:
Macphee GJA, Crowther JA, McAlpine CH. A simple screening test for hearing impairment in elderly
patients. Age Ageing. 1988;17(5):347-351.

6 Inches 2 Feet
Conversational voice Whisper Conversational voice Whisper
Left Ear
Right Ear

23
7) Pengkajian Kesehatan Mental/ Resiko Depresi

Geriatric Depression Scale (Short Form)

Patients Name: Date: _________________________

Instructions: Choose the best answer for how you felt over the past week. Note: when
asking the patient to complete the form, provide the self-rated form (included on the
following page).

No. Question Answer Score


1. Are you basically satisfied with your life? YES / NO
2. Have you dropped many of your activities and interests? YES / NO
3. Do you feel that your life is empty? YES / NO
4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time? YES / NO
6. Are you afraid that something bad is going to happen to you? YES / NO

7. Do you feel happy most of the time? YES / NO


8. Do you often feel helpless? YES / NO
9. Do you prefer to stay at home, rather than going out and doing YES / NO
new things?
10. Do you feel you have more problems with memory than most YES / NO
people?
11. Do you think it is wonderful to be alive? YES / NO
12. Do you feel pretty worthless the way you are now? YES / NO
13. Do you feel full of energy? YES / NO
14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you are? YES / NO
TOTAL
(Sheikh & Yesavage, 1986)
Scoring:
Answers indicating depression are in bold and italicized; score one point for each one selected. A
score of 0 to 5 is normal. A score greater than 5 suggests depression.

Sources:
Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and
development of a shorter version. Clin Gerontol. 1986 June;5(1/2):165-173.
Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull. 1988;24(4):709-711.
Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression
screening scale:
a preliminary report. J Psychiatr Res. 1982-83;17(1):37-49

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