76

FORMAT PENGKAJIAN KEPERAWATAN GERONTIK

No. Register :

Ruang/Wisma :

Tgl/ Jam Pengkajian :

Diagnosa Medis :

Lama tinggal di panti :

1. IDENTITAS

a. IdentitasPasien

Nama :

Umur :

JenisKelamin :

Agama :

Pendidikan :

Pekerjaan :

Suku / Bangsa :

Alamat :

b. IdentitasPenanggungJawab

Nama :

Umur :

JenisKelamin :

Agama :

Pekerjaan :
 77

Alamat :

Hubungandenganpx :

2. RIWAYAT KESEHATAN

a. KeluhanUtama

........................................................................................................................

........................................................................................................................

b. RiwayatPenyakitSekarang

........................................................................................................................

........................................................................................................................

c. RiwayarPenyakitDahulu

........................................................................................................................

........................................................................................................................

3. POLA AKTIVITAS SEHARI-HARI

a. Nutrisi

........................................................................................................................

........................................................................................................................

b. Eliminasi

..................................................................................................................

..................................................................................................................

c. Istirahatdantidur
 78

..................................................................................................................

..................................................................................................................

d. AktivitasFisik

..................................................................................................................

..................................................................................................................

e. Personal hygiene

..................................................................................................................

..................................................................................................................

f. Ketergantungan

..................................................................................................................

..................................................................................................................

4. DATA PSIKOSOSIAL

a. Status Emosi

........................................................................................................................

........................................................................................................................

b. KonsepDiri

1) Body image :

2) Self ideal :

3) Self esteem :

4) Role :

5) Identity :

c. Interaksisosial
 79

........................................................................................................................

........................................................................................................................

d. Spiritual

........................................................................................................................

........................................................................................................................

5. PEMERIKSAAN FISIK

a. KeadaanUmum

........................................................................................................................

........................................................................................................................

b. Kesadaran

........................................................................................................................

........................................................................................................................

c. Tanda-tanda vital

........................................................................................................................

........................................................................................................................

d. Kepala

........................................................................................................................

........................................................................................................................

e. Leher

........................................................................................................................

........................................................................................................................

f. Dada danThorak
 80

........................................................................................................................

........................................................................................................................

g. Abdomen

........................................................................................................................

........................................................................................................................

h. Ekstremitas

........................................................................................................................

........................................................................................................................

i. Genetalia

........................................................................................................................

........................................................................................................................

6. PEMERIKSAAN PENUNJANG

...............................................................................................................................

...............................................................................................................................

7. TERAPI DAN PENATALAKSANAAN

...............................................................................................................................

...............................................................................................................................

8. PENGKAJIAN FUNGSIONAL
 81

Katz index
No Kegiatan Mandiri Bantuansebagian Bantuanpenuh
1 Mandi
2 Berpakaian
3 Kekamarkecil
4 Berpindahtempat
5 BAB/BAK
6 Makan/minum
Keterangan :

Kliendapatberaktivitassecaramandiritanpapengawasan, pengarahan,

ataubantuanaktifdari orang lain.

9. STATUS KOGNITIF ATAU AFEKTIF

a. Short Portable Mental Status Questionare(SPMSQ)

Pertanyaan :

Benar Salah Nomor Pertanyaan jawaban

1 Tanggalberapahariini?

2 Hariapasekarang ?

3 Apanamatempatini?

4 Dimanaalamatanda?

5 Berapaumuranda?

6 Kapanandalahir?

7 Siapapresiden Indonesia?

Benar Salah Nomor Pertanyaan jawaban

 82

8 Siapapresiden Indonesia
sebelumnya?

9 Siapanamakecilanda?

10 Kurangi 3 dari 20
dantetappengurangan 3
darisetiapangkabarusecaramenurun

Jumlah : Benar :
Salah :
Interpretasi :

Salah 0-3 :fungsiintelektualutuh

Salah 4-5 :fungsiintelektualkerusakanringan

Salah 6-8 :fungsiintelektualkerusakansedang

Salah 9-10 :fungsiintelektualkerusakanberat

b. MMSE (Mini Mental Status Exam)

Skormaksimum Skorlansia Orientasi

5 0 Sekarang (hari), (tanggal), (bulan), (tahun), (musim) apa?
5 0 Sekarangkitaberadadimana? (jalan), (no rumah), (kota), (kabupaten),
?
Registrasi
3 0 Pewawancaramenyebutkannama 3 buahbenda, 1 detikuntukt
Kemudianmintalahlansiamengulangke 3 nam
Berikansatuangkauntuksetiapjawaban yang benar. Bilam
ulanglahpenyebutanke 3 nam
sampaiiadapatmengulangnyadenganbenarhitunglahjumlahpercobaand
(bola, kursi, sepatu)
Jumlahpercobaan……………….
Atensidankalkulasi

Skormaksimum Skorlansia Orientasi

5 0 Hitunglahberturut-turutselang 7 mulaidari 100 kebaw
angkauntuktiapjawaban yang benar. Berhentisetellah 5 hit
(93,86,79,72,65). Kemungkinan lain: ejalah kata: dunia” dariakhirke
 83

n-u-d)
Mengingatkembali (Recall)
3 0 Tanyalahkembalinamake 3 benda yang telahdisebutkamdiatas. B
angkauntuksetiapjawaban yang benar
Bahasa
9 0 a. Apakahnamabenda-bendaini? (perlihatkanpensildanalorji) (2 ang
b. Ulanglahkalimatberikut: “jikatidakadadiadanatautapi” (1 angka)
c. Laksanakan 3 buahp
“peganglahselembarkertasdengantangankananmu,
lipatlahkertasitupadapertengahandanletakkandilantai (3 angka)
d. Bacalahdanlaksanakanperintahberikut: pejamkanmataanda (1 ang
e. Tulislahsebuahkalimat (1 angka)
f. Tirulahgambarini (1 angka)

Skor total 0
Skor : Nilai 24-30 : normal

Nilai 17-23 : probable gangguankognitif

Nilai 0-16 definitifgangguankognitif

Yang MelakukanPengkajian

ttd
 84

Lampiran4

ANALISA DATA

Nama : Ruang :

Umur : No.RM :

Data Subyektifdan Data

Tgl / Jam Etiologi Masalah
Obyektif
 85

Lampiran5

DIAGNOSA KEPERAWATAN

Nama : Ruang :

Umur : No. RM :

No. Tgl/Jam Diagnosis Keperawatan

 86

FORMAT PENGKAJIAN KEPERAWATAN GERONTIK

No. Register :

Ruang/Wisma :

Tgl/ Jam Pengkajian :

Diagnosa Medis :

Lama tinggal di panti :

10. IDENTITAS

c. IdentitasPasien

Nama :

Umur :

JenisKelamin :

Agama :

Pendidikan :

Pekerjaan :

Suku / Bangsa :

Alamat :

d. IdentitasPenanggungJawab

Nama :

Umur :

JenisKelamin :

Agama :

Pekerjaan :
 87

Alamat :

Hubungandenganpx :

11. RIWAYAT KESEHATAN

d. KeluhanUtama

........................................................................................................................

........................................................................................................................

e. RiwayatPenyakitSekarang

........................................................................................................................

........................................................................................................................

f. RiwayarPenyakitDahulu

........................................................................................................................

........................................................................................................................

12. POLA AKTIVITAS SEHARI-HARI

g. Nutrisi

........................................................................................................................

........................................................................................................................

h. Eliminasi

..................................................................................................................

..................................................................................................................

i. Istirahatdantidur
 88

..................................................................................................................

..................................................................................................................

j. AktivitasFisik

..................................................................................................................

..................................................................................................................

k. Personal hygiene

..................................................................................................................

..................................................................................................................

l. Ketergantungan

..................................................................................................................

..................................................................................................................

13. DATA PSIKOSOSIAL

e. Status Emosi

........................................................................................................................

........................................................................................................................

f. KonsepDiri

6) Body image :

7) Self ideal :

8) Self esteem :

9) Role :

10) Identity :

g. Interaksisosial
 89

........................................................................................................................

........................................................................................................................

h. Spiritual

........................................................................................................................

........................................................................................................................

14. PEMERIKSAAN FISIK

a. KeadaanUmum

........................................................................................................................

........................................................................................................................

b. Kesadaran

........................................................................................................................

........................................................................................................................

c. Tanda-tanda vital

........................................................................................................................

........................................................................................................................

d. Kepala

........................................................................................................................

........................................................................................................................

e. Leher

........................................................................................................................

........................................................................................................................

f. Dada danThorak
 90

........................................................................................................................

........................................................................................................................

g. Abdomen

........................................................................................................................

........................................................................................................................

h. Ekstremitas

........................................................................................................................

........................................................................................................................

i. Genetalia

........................................................................................................................

........................................................................................................................

15. PEMERIKSAAN PENUNJANG

...............................................................................................................................

...............................................................................................................................

16. TERAPI DAN PENATALAKSANAAN

...............................................................................................................................

...............................................................................................................................

17. PENGKAJIAN FUNGSIONAL

 91

Katz index
No Kegiatan Mandiri Bantuansebagian Bantuanpenuh
1 Mandi
2 Berpakaian
3 Kekamarkecil
4 Berpindahtempat
5 BAB/BAK
6 Makan/minum
Keterangan :

Kliendapatberaktivitassecaramandiritanpapengawasan, pengarahan,

ataubantuanaktifdari orang lain.

18. STATUS KOGNITIF ATAU AFEKTIF

a. Short Portable Mental Status Questionare(SPMSQ)

Pertanyaan :

Benar Salah Nomor Pertanyaan jawaban

1 Tanggalberapahariini?

2 Hariapasekarang ?

3 Apanamatempatini?

4 Dimanaalamatanda?

5 Berapaumuranda?

6 Kapanandalahir?

7 Siapapresiden Indonesia?

Benar Salah Nomor Pertanyaan jawaban

 92

8 Siapapresiden Indonesia
sebelumnya?

9 Siapanamakecilanda?

10 Kurangi 3 dari 20
dantetappengurangan 3
darisetiapangkabarusecaramenurun

Jumlah : Benar :
Salah :
Interpretasi :

Salah 0-3 :fungsiintelektualutuh

Salah 4-5 :fungsiintelektualkerusakanringan

Salah 6-8 :fungsiintelektualkerusakansedang

Salah 9-10 :fungsiintelektualkerusakanberat

b. MMSE (Mini Mental Status Exam)

Skormaksimum Skorlansia Orientasi

5 0 Sekarang (hari), (tanggal), (bulan), (tahun), (musim) apa?
5 0 Sekarangkitaberadadimana? (jalan), (no rumah), (kota), (kabupaten),
?
Registrasi
3 0 Pewawancaramenyebutkannama 3 buahbenda, 1 detikuntukt
Kemudianmintalahlansiamengulangke 3 nam
Berikansatuangkauntuksetiapjawaban yang benar. Bilam
ulanglahpenyebutanke 3 nam
sampaiiadapatmengulangnyadenganbenarhitunglahjumlahpercobaand
(bola, kursi, sepatu)
Jumlahpercobaan……………….
Atensidankalkulasi

Skormaksimum Skorlansia Orientasi

5 0 Hitunglahberturut-turutselang 7 mulaidari 100 kebaw
angkauntuktiapjawaban yang benar. Berhentisetellah 5 hit
(93,86,79,72,65). Kemungkinan lain: ejalah kata: dunia” dariakhirke
 93

n-u-d)
Mengingatkembali (Recall)
3 0 Tanyalahkembalinamake 3 benda yang telahdisebutkamdiatas. B
angkauntuksetiapjawaban yang benar
Bahasa
9 0 g. Apakahnamabenda-bendaini? (perlihatkanpensildanalorji) (2 ang
h. Ulanglahkalimatberikut: “jikatidakadadiadanatautapi” (1 angka)
i. Laksanakan 3 buahp
“peganglahselembarkertasdengantangankananmu,
lipatlahkertasitupadapertengahandanletakkandilantai (3 angka)
j. Bacalahdanlaksanakanperintahberikut: pejamkanmataanda (1 ang
k. Tulislahsebuahkalimat (1 angka)
l. Tirulahgambarini (1 angka)

Skor total 0
Skor : Nilai 24-30 : normal

Nilai 17-23 : probable gangguankognitif

Nilai 0-16 definitifgangguankognitif

Yang MelakukanPengkajian

ttd
 94

ANALISA DATA

Nama : Ruang :

Umur : No.RM :

Data Subyektifdan Data

Tgl / Jam Etiologi Masalah
Obyektif
 95

DIAGNOSA KEPERAWATAN

Nama : Ruang :

Umur : No. RM :

No. Tgl/Jam Diagnosis Keperawatan

 96

FORMAT PERENCANAAN KEPERAWATAN

Nama : Ruang :

Umur : No. Register :

No Diagnosa Tujuan Intervensi Rasional

 97

FORMAT IMPLEMENTASI KEPERAWATAN

Nama : Ruang :

Umur : No. Register :

No DiagnosaKeperawatan Tanggal/ Tindakan Respon

Jam
 98

FORMAT EVALUASI KEPERAWATAN

Nama : Ruang :

Umur : No. Register :

No DiagnosaKeperawatan Tanggal/ Jam Evaluasi