FORMAT PENGKAJIAN

ASUHAN KEPERAWATAN GERONTIK

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

NIM : ....................................................................................................

Tanggal Pengkajian : ....................................................................................................

A. PENGKAJIAN
1. Identitas Klien
a. Nama : ...................................................................................................................................................................
b. Tempat, tanggal lahir : ...................................................................................................................................................................
c. Jenis kelamin : ...................................................................................................................................................................
d. Status perkawinan : ...................................................................................................................................................................
e. Agama : ...................................................................................................................................................................
f. Suku : ...................................................................................................................................................................
g. Alamat : ...................................................................................................................................................................
2. Riwayat Pekerjaan Status
a. Pekerjaan Saat Ini : .................................................................................................................................................................
b. Pekerjaan Sebelumnya : .................................................................................................................................................................
c. Sumber Pendapatan : .................................................................................................................................................................
d. Kecukupan Pendapatan : .................................................................................................................................................................

3. Lingkungan Tempat Tinggal

a. Kebersihan dan kerapihan lingkungan : ....................................................................................................................................
b. Penerangan : ....................................................................................................................................
c. Sirkulasi udara : ....................................................................................................................................
d. Keadaan kamar mandi dan WC : ....................................................................................................................................
e. Pembuangan Air Kotor : ....................................................................................................................................
f. Sumber Air munum : ....................................................................................................................................
g. Pembuangan sampah : ....................................................................................................................................
h. Sumber pencemaran : ....................................................................................................................................
i. Privasi : ....................................................................................................................................
j. Resiko injuri : ....................................................................................................................................
4. Riwayat Kesehatan
a. Status Kesehatan Saat Ini
1. Keluhan utama dalam 1 tahun terakhir
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2. Gejala yang dirasakan
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3. Faktor Pencetus
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4. Timbulnya Keluhan
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5. Upaya Mengatasi
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6. Pergi ke RS/Klinik Pengobatan/ dokter Praktek/Bidan/Perawat
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 7. Mengkonsumsi obat-obatan sendiri/obat tradisional
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b. Status Kesehatan Masa Lalu

1. Penyakit yang pernah diderita
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2. Riwayat alergi
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3. Riwayat kecelakaan
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4. Riwayat pernah dirawat di RS
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5. Riwayat pemakaian obat
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5. Pola Fungsi Sosial
a. Presepsi kesehatan
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b. Nutrisi
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c. Eliminasi
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d. Aktifitas pola latihan
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e. Pola Istirahat
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f. Pola Kognitif
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g. Konsep Diri
1) Gambaran Diri
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2) Identitas Diri
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3) Peran Diri
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4) Ideal Diri
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5) Harga Diri
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 h. Pola Peran-Hubungan
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i. Sexsualitas
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j. Pola Toleransi Stress
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k. Nilai Keyakinan
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6. Pemeriksaan Fisik
a. Keadaan Umum
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b. TTV
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c. BB/TB
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d. Kepala
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e. Rambut
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f. Mata
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g. Telinga
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h. Mulut, gigi & bibir
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i. Dada
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j. Abdomen
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k. Kulit
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l. Ekstremitas atas
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m. Ekstremitas bawah
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7. Pengkajian Khusus
a. Fungsi Kognitif SPMSQ

SKORE
+ - No. PERTANYAAN JAWABAN
1. Tanggal berapa hari ini ?
2. Hari apa sekarang ini ?
3. Apa nama tempat ini ?
4. Di desa mana anda tinggal?
5. Berapa umur Anda ?
6. Kapan Anda lahir ?
7. Siapa Presiden Indonesia sekarang ?
8. Siapa Presiden sebelumnya ?
9. Siapa nama kecil ibu Anda ?
10. Kurangi 3 dari 20 dan tetap pengurangan 3 dari setiap angka
baru, semua secara menurun ?
Jumlah Kesalahan Total

KETERANGAN :
1. Kesalahan 0 – 2 Fungsi intelektual utuh
2. Kesalahan 3 – 4 Kerusakan intelektual Ringan
3. Kesalahan 5 – 7 Kerusakan intelektual Sedang
4. Kesalahan 8 – 10 Kerusakan intelektual Berat

b. Status Fungsional (Katz Indeks)

 SKORE KRITERIA
Kemandirian dalam hal makan, kontinen, berpindah, ke kamar kecil, berpakaian dan mandi
A

Kemandirian dalam semua aktivitas hidup sehari-hari, kecuali kontinen

B

Kemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi

C

Kemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi, berpakaian

D

Kemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi, berpakaian, kekamar kecil
E

Kemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi, berpakaian, kekamar kecil, berpindah
F

G Ketergantungan pada ke enam fungsi tersebut

c. Mini Mental State Examination (MMSE)

 NILAI PASIEN PERTANYAAN
Maksimum
ORIENTASI
5
(Tahun, Musim, Tgl, Hari, Bulan, apa sekarang ? dimana
5 kita : (Negara Bagian, Wilayah, Kota) di RS, Lantai ?)

REGISTRASI
Nama 3 Obyek (1 detik untuk mengatakan masing-masing) tanyakan klien ke 3 obyek setelah
3 anda telah mengatakan. Beri 1 point untuk tiap jawaban yang benar, kemudian ulangi sampai
ia mempelajari ke 3 nya jumlahkan percobaan & catat. Percobaan : ……………………
PERHATIAN & KALKULASI
Seri 7's ( 1 point tiap benar, berhenti setelah 5 jawaban, berganti eja kata ke belakang) ( 7 kata
5 dipilih eja dari belakang)
MENGINGAT
3 Minta untuk mengulangi ke 3 obyek diatas, beri 1 point untuk tiap kebenaran.
BAHASA
Menyebutkan 2 benda (2 point)
9
30 Nilai Total

KETERANGAN :
Mengkaji Tingkat Kesadaran klien sepanjang Kontinum :
Composmentis, Apatis, Somnolens, Suporus, Coma.
Nilai < 21 indikasi ada kerusakan kognitif perlu penyelidikan lanjut)
d. APGAR Keluarga

NO. URAIAN FUNGSI SKORE

1. Saya puas bahwa saya dapat kembali pada keluarga (teman-teman)
saya untuk membantu pada waktu sesuatu menyusahkan saya. ADAPTATION

2. Saya puas dengan cara keluarga (teman-teman) saya membicarakan

sesuatu dengan saya & mengungkap- kan masalah dengan saya PARTNERSHIP

3. Saya puas dengan cara keluarga (teman-teman) saya menerima &

mendukung keinginan saya untuk melakukan aktivitas / arah baru GROWTH

4. Saya puas dengan cara keluarga (teman-teman) saya

mengekspresikan afek & berespons terhadap emosi-emosi saya AFFECTION

seperti marah, sedih / mencintai.

5. Saya puas dengan cara teman-teman saya & saya menyediakan
waktu bersama-sama. RESOLVE

PENILAIAN :
Pertanyaan-pertanyaan yang di Jawab :
 Selalu : Skore 2
 Kadang-kadang : Skore 1
 Hampir Tidak Pernah : Skore 0
e. Skala Depresi
NO. PERTANYAAN YA TIDAK
1 Apakah anda sebenarnya puas dengan kehidupan anda?
2 Apakah anda telah meninggalkan banyak kegiatan dan minat/kesenangan anda?
3 Apakah anda merasa kehidupan anda kosong?
4 Apakah anda merasa sering bosan?
5 Apakah anda mempunyai semangat yang baik setiap saat?
6 Apakah anda merasa takut sesuatu yang buruk akan terjadi pada anda?
7 Apakah anda merasa bahagia untuk sebagian besar hidup anda?
8 Apakah anda sering merasa tidak berdaya?
9 Apakah anda sering dirumah daripada pergi keluar dan mengerjakan sesuatu hal yang baru?
10 Apakah anda merasa mempunyai banyak masalah dengan daya ingat anda dibandingkan
kebanyakan orang
11 Apakah anda pikir bahwa kehidupan anda sekarang menyenangkan?
12 Apakah anda merasa tidak berharga seperti perasaan anda saat ini?
13 Apakah anda merasa penuh semangat?
14 Apakah anda merasa bahwa keadaan anda tidak ada harapan?
15 Apakah anda pikir bahwa orang lain, lebih baik keadaanya daripada anda?
KETERANGAN:
Setiap jawaban yang sesuai mempunyai skor 1
Skor 5-9 : Kemugkinan Depresi
Skor 10 atau lebih : Depresi
f. Screening Faal
NO LANGKAH SKOR
1 Minta pasien berdiri di sisi tembok dengan tangan direntangkan ke depan
2 Beri tanda letak tangan I
3 Minta pasien condong kedepan tanpa melangkah selama 1-2 menit dengan tangan
direntangkan kedepan
4 Beri tanda letak tangan ke II pada posisi condong
5 Ukur jarak antara tanda tangan ke I dan tangan ke II
Interpretasi:
Usia >70 tahun : kurang 6 inchi Resiko roboh

g. Skala Norton
Penilaian Variabel Skor
Kondisi Fisik Baik Lumayan Buruk Sangat Buruk
Umum
Kesadaran Composmentis Apatis Konfus Koma
Aktivitas Ambulan Ambulan dengan Hanya bisa duduk tiduran
bantuan
Mobilitas Bergerak bebas Sedikit terbatas Sangat terbatas Tak bisa bergerak
KETERANGAN:
 Skor 16-20 : Kecil Sekali/ tidak terjadi
Skor 12-15: kemungkinan kecil terjadi
Skor <12 : kemungkinan besar terjadi

h. Mini Nutritional Asessment (MNA)