PENGKAJIAN

KEPERAWATAN GERONTIK

Tanggal Pengkajian:
A. KARAKTERISTIK DEMOGRAFI
1. Identitas diri Klien
a. Nama :
b. Tempat/tgl lahir :
c. Jenis kelamin :
d. Pendidikan terakhir :
e. Golongan darah :
f. Agama :
g. Status perkawinan :
h. Alamat :

Keluarga yang dapat dihubungi

a. Nama :
b. Alamat :

c. No. Telp :
d. Jenis Kelamin :
e. Hubungan dengan klien :

2. Riwayat pekerjaan :
3. Aktivitas rekreasi :

4. Riwayat keluarga :
Genogram
Keterangan:
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

a. Saudara/anak kandung :
b. Riwayat kematian dalam keluarga :
c. Kunjungan keluarga :

B. POLA KEBIASAAN SEHARI-HARI

1. Nutrisi :
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
2. Eliminasi :
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
3. Personal hygiene
a. Mandi:
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
b. Oral hygiene:
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
c. Cuci rambut:
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
d. Kuku dan tangan:
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
e. Istirahat dan tidur:
 .................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
f. Kebiasaan mengisi waktu luang:
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
g. Kebiasaan yang mempengaruhi kesehatan:
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

h. Uraian kronologis kegiatan sehari-hari:

No Waktu Kegiatan

C. STATUS KESEHATAN
1. Status kesehatan saat ini
a. Keluhan utama 1 tahun terakhir :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
b. Gejala yang dirasakan :
 ....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
c. Faktor pencetus :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
d. Timbulnya keluhan :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
e. Waktu timbulnya keluhan :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
f. Upaya mengatasi :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

2. Riwayat kesehatan masa lalu

a. Penyakit yang pernah diderita :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
b. Riwayat alergi :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
c. Riwayat kecelakaan :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
d. Riwayat di rawat di rumah sakit :
....................................................................................................................................
 ....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
e. Riwayat pemakaian obat :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

D. AGE RELATED CHANGE

1. Perubahan Fisik
Sistem Persyarafan
 Headache :
 Seizures :
 Syncope :
 Tic/tremmor :
 Paralysis :
 Paresis :
 Masalah memori :
Jelaskan
(uraikan jika terdapat hasil yang abnormal dari hasil identifikasi atau jika
terdapat hal lain yang diperoleh diluar dari yang seharusnya diidentifikasi)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
Sistem Pendengaran
 Penurunan pendengaran :
 Discharge :
 Tinitus :
 Vertigo :
 Alat bantu dengar :
 Riwayat infeksi :
 Kebiasaan membersihkan telinga :
 Dampak pada ADL :
Jelaskan
(uraikan jika terdapat hasil yang abnormal dari hasil identifikasi atau jika
terdapat hal lain yang diperoleh diluar dari yang seharusnya diidentifikasi)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
Sistem Penglihatan
 Perubahan penglihatan :
 Pakai kacamata :
 Kekeringan mata :
 Nyeri :
 Gatal :
 Photopobia :
 Diplopia :
 Riwayat infeksi :
Jelaskan
(uraikan jika terdapat hasil yang abnormal dari hasil identifikasi atau jika
terdapat hal lain yang diperoleh diluar dari yang seharusnya diidentifikasi)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
Sistem Penciuman
 Rhinorea :
 Discharge :
 Epistaksis :
 Obstruksi :
 Snoring :
 Alergi :
Jelaskan
(uraikan jika terdapat hasil yang abnormal dari hasil identifikasi atau jika
terdapat hal lain yang diperoleh diluar dari yang seharusnya diidentifikasi)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
Sistem Gastrointestinal
 Disphagia :
 Nausea/vomiting :
 Hemateemesis :
 Perubahan nafsu makan :
 Massa :
 Jaundice :
 Perubahan pola BAB :
 Melena :
 Haemorhoid :
Jelaskan
(uraikan jika terdapat hasil yang abnormal dari hasil identifikasi atau jika
terdapat hal lain yang diperoleh diluar dari yang seharusnya diidentifikasi)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
 .................................................................................................................................
.................................................................................................................................
Sistem Genitourinarius
 Dysuria :
 Frekuensi :
 Hesitancy :
 Urgency :
 Hematuria :
 Poliuria :
 Oliguria :
 Nocturia :
 Inkontinensia :
 Nyeri berkemih :
 Pola BAK :
Jelaskan
(uraikan jika terdapat hasil yang abnormal dari hasil identifikasi atau jika terdapat
hal lain yang diperoleh diluar dari yang seharusnya diidentifikasi)
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Sistem Integument
 Lesi/luka :
 Pruritis :
 Perubahan pigmen :
 Memar :
 Pola penyembuhan lesi :
Jelaskan
(uraikan jika terdapat hasil yang abnormal dari hasil identifikasi atau jika terdapat
hal lain yang diperoleh diluar dari yang seharusnya diidentifikasi)
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 .....................................................................................................................................
Sistem Muskuloskletal
 Nyeri sendi :
 Bengkak :
 Kaku sendi :
 Deformitas :
 Spasme :
 Kram :
 Kelemahan otot :
 Gaya berjalan :
 Nyeri punggung :
Jelaskan
(uraikan jika terdapat hasil yang abnormal dari hasil identifikasi atau jika terdapat
hal lain yang diperoleh diluar dari yang seharusnya diidentifikasi. Identifikasi
kekuatat otot pasien)
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Sistem Kardiovaskuler
 Chest pain :
 Palpitasi :
 Dipsnoe :
 Paroximal nocturnal :
 Orthopnea :
 Murmur :
 Edema :
Jelaskan
(uraikan jika terdapat hasil yang abnormal dari hasil identifikasi atau jika terdapat
hal lain yang diperoleh diluar dari yang seharusnya diidentifikasi. Cantumkan
hasil pemeriksaan TTV)
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

2. Perubahan Psikologis
a. Bagaimana sikap lansia terhadap proses penuaan,
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
b. Apakah dirinya merasa di butuhkan atau tidak,
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
 ....................................................................................................................................
c. Apakah optimis dalam memandang suatu kehidupan,
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
d. Bagaimana mengatasi stres yang di alami,
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
e. Apakah mudah dalam menyesuaikan diri,
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
f. Apakah lansia sering mengalami kegagalan,
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
g. Apakah harapan pada saat ini dan akan datang,
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

3. Perubahan Sosial Ekonomi

a. Darimana sumber keuangan lansia,
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
b. Apa saja kesibukan lansia dalam mengisi waktu luang,
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
c. Dengan siapa dia tinggal,
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
 d. Kegiatan organisasi apa yang diikuti lansia,
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
e. Bagaimana pandangan lansia terhadap lingkungannya,
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
f.Seberapa sering lansia berhubungan dengan orang lain di luar rumah,
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
g. Siapa saja yang bisa mengunjungi,
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
h. Seberapa besar ketergantungannya,
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
i. Apakah dapat menyalurkan hobi atau keinginan dengan fasilitas yang ada.
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

3. Perubahan Spiritual
a. Apakah secara teratur melakukan ibadah sesuai dengan keyakinan agamanya,
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
b. Apakah secara teratur mengikuti atau terlibat aktif dalam kegiatan keagamaan,
misalnya pengajian dan penyantunan anak yatim atau fakir miskin.
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
 c. Bagaimana cara lansia menyelesaikan masalah apakah dengan berdoa,
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
d. Apakah lansia terlihat tabah dan tawakal.
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................

E. PENGKAJIAN KHUSUS (PSIKOGERIATRIK)

 Pengkajian status fungsional dengan pemeriksaan index kats
NO AKTIVITAS MANDIRI TERGANTUNG
1. Mandi
Mandiri:
Bantuan hanya pada satu bantuan mandi
(seperti punggung atau ekstermitas yang tidak
mampu) atau mandi sendiri sepenuhnya
Tergantung:
Bantuan mandi lebih dari satu bantuan tubuh,
bantuan masuk dan keluar dari bak mandi,
serta tidak mandi sendiri
2. Berpakaian
Mandiri:
Mengambil baju dari lemari, memakai
pakaian, melepas pakaian, mengancing atau
mengikat pakaian.
Tergantung:
Tidak dapat memakai baju sendir atau hanya
sebagian
3. Ke kamar kecil
Mandiri:
Masuk dan keluar dari kamar kecil kemudian
membersihkan genetalia sendiri
Tergantung:
Menerima bantuan untuk masuk ke kamar
kecil dan menggunakan pispot
4. Berpindah
Mandiri:
Berpindah ked an dari tempat tidur untuk
duduk, bangkit dari kursi sendiri
Bergantung:
Bantuan dalam naik atau turun dari tempat
tidur atau kursi, tidak melakukan satu, atau
lebih perpindahan
5. Kontinen
 Mandiri:
BAK dan BAB seluruhnya di control sendiri
Tergantung:
Inkontenensia persial atau total, penggunaan
kateter, pispot, enema dan pembalut
(pempers)
6. Makan
Mandiri:
Mengambil makanan dari piring dan
menyuapinya sendiri
Bergantung:
Bantuan dalam hal mengambil makanan dari
piring dan menyuapinya, tidak makan sama
sekali dan makan parenteral (NGT)
Keterangan :
Beri tanda (  ) pada point yang sesuai kondisi klien
ANALISIS HASIL
Nilai A Kemandirian dalam hal makan, kontinen ( BAK/BAB ), berpindah,
kekamar kecil, mandi dan berpakaian.
Nilai B Kemandirian dalam semua hal kecuali satu dari fungsi tersebut
Nilai C Kemandirian dalam semua hal, kecuali mandi dan satu fungsi tambahan
Nilai D Kemandirian dalam semua hal, kecuali mandi, berpakaian, dan satu fungsi
tambahan
Nilai E Kemandirian dalam semua hal kecuali mandi, berpakaian, ke kamar kecil,
dan satu fungsi tambahan.
Nilai F Kemandirian dalam semua hal kecuali mandi, berpakaian, ke kamar kecil,
berpindah dan satu fungsi tambahan
Nilai G Ketergantungan pada keenam fungsi tersebut
Lain-lain Tergantung pada sedikitnya dua fungsi, tetapi tidak dapat diklasifikasikan
sebagai C,D,E atau F
  Pengkajian status fungsional dengan pemeriksaan Barthel indeks
Dengan
No Kriteria Mandiri Keterangan
Bantuan
1 Makan

2 Minum

3 Berpindah dari satu tempat

ketempat lain

4 Personal toilet (cuci muka,

menyisir rambut, gosok gigi).

5 Keluar masuk toilet

( mencuci pakaian, menyeka
tubuh, meyiram)
6 Mandi

7 Jalan dipermukaan datar

8 Naik turun tangga

9 Mengenakan pakaian

10 Kontrol Bowel (BAB)

11 Kontrol Bladder (BAK)

12 Olah raga/ latihan

13 Rekreasi/ pemanfaatan waktu
luang

Keterangan:
1. 130 : Mandiri
2. 65-125 : Ketergantungan Sebagian
3. 60 : Ketergantungan Total
  Pengkajian status kognitif dengan short portable mental status questionare (SPMSQ)
Benar Salah No Pertanyaan
01 Tanggal berapa hari ini?
02 Hari apa sekarang?
03 Apa nama tempat ini?
04 Dimana alamat anda?
05 Berapa umur anda?
06 Kapan anda lahir?
07 Siapa presiden Indonesia sekarang?
08 Siapa presiden Indonesia sebelumnya?
09 Siapa nama ibu anda?
Jumla Jumla 10 Kurangi 3 dari 20 dan tetap pengurangan 3 dari setiap
h h angka baru, semua secara menurun

Interpretasi Hasil:
a. Salah 0-3: Fungsi Intelektual Utuh
b. Salah 4-5 : Kerusakan Intelektual Ringan
c. Salah 6-8 : Kerusakan Intelektual Sedang
d. Salah 9-10: Kerusakan Intelektual Berat
 Pengkajian status kognitif dengan mini mental state exam (MMSE)
NILAI
ITEM TES NILAI
MAX

ORIENTASI

1 Sekarang (tahun), (musim), (bulan), (tanggal), (hari) 5

apa?
5
Kita berada di mana? (negara), (provinsi), (kota), (rumah
2
sakit), (lantai/kamar)
REGISTRASI

3 Sebutkan 3 buah nama benda (apel, meja, koin) tiap 3

benda 1 detik, pasien disuruh mengulangi ketiga nama
benda tersebut dengan benar dan catat jumlah
pengulangan
ATENSI DAN KALKULASI

4 Kurangi 100 dengan 7. Nilai 1 untuk setiap jawaban 5

benar. Hentikan setelah 5 jawaban. Atau disuruh
mengeja terbalik kata “DUNIA” (nilai diberikan pada
huruf yang benar sebelum kesalaahn; misalnya
“aiund”=3
5 MENGINGAT KEMBALI (RECALL)

Klien diminta mengingat kembali nama benda di atas 3

BAHASA

6 Klien diminta menyebutkan nama benda yang 2

ditunjukkan (taplak meja, pen)

Klien diminta mengulang kata-kata “namun”, “tanpa”,

7 1
“bila”

Klien diminta melakukan perintah : “Ambil kertas ini

8 dengan tangan Anda, lipatlah menjadi dua bagian dan 3
letakkan di lantai”
 Klien disuruh membaca dan melakukan perintah
“Pejamkan mata Anda”

Klien disuruh menulis dengan spontan

9 1
Klien diminta menggambarkan bentuk di bawah ini
10 1

11 1

TOTAL 30

Keterangan :
1. Skor 24-30 : Normal
2. Nilai 18-23 : Gangguan kognitif sedang
3. Nilai 0-17 : Gangguan kognitif berat
 Pengkajian status depresi dengan Geriatric Depretion Scale (GDS)
PERTANYAAN JAWABAN SKOR
YA/
TIDAK
a. Apakah pada dasarnya anda puas dengan kehidupan anda?
b. Apakah anda telah meninggalkan banyak kegiatan atau
minat atau kesenangan anda?
c. Apakah anda merasa bahwa hidup ini kosong belaka?
b. Apakah anda merasa sering bosan?
c. Apakah anda mempunyai semangat yang baik setiap saat?
d. Apakah anda takut sesuatu yang buruk akan terjadi pada
anda?
e. Apakah anda merasa bahagia di sebagian besar hidup
anda?
f. Apakah anda merasa sering tidak berdaya?
g. Apakah anda lebih senang tinggal di rumah dari pada pergi
keluar dan mengerjakan sesuatu yang baru?
h. Apakah anda merasa mempunyai banyak masalah dengan
daya ingat anda dibandingkan kebanyakan orang?
i. Apakah anda pikir bahwa hidup anda sekarang ini
menyenangkan?
j. Apakah anda merasa berharga?
k. Apakah anda merasa penuh semangat?
l. Apakah anda merasa bahwa keadaan anda tidak ada
harapan?
m. Apakah anda pikir orang lain lebih baik keadaanya
daripada anda?
Jumlah

Nilai 1 jika menjawab sesuai kunci berikut :

a. Tidak i. Ya
b. Ya j. Ya
c. Ya k. Tidak
d. Ya l. Ya
e. Tidak m. Tidak
 f. Ya n. Ya
g. Tidak o. Ya
h. Ya
Skor :
5-9 : Kemungkinan depresi
10 atau lebih : Depresi
Kesimpulan :
  Pengkajian fungsi sosial dengan APGAR keluarga (Adaptation, Partnership, Growth,
Affection, Resolve)
KADANG
SELALU TIDAK
-
NO ITEMS PENILAIAN PERNAH
KADANG
(2) (0)
(1)
1 A : Adaptasi
Saya puas bahwa saya dapat kembali
pada keluarga ( teman-teman ) saya
untuk membantu pada waktu sesuatu
menyusahkan saya
2 P : Partnership
Saya puas dengan cara keluarga (teman-
teman) saya membicarakan sesuatu
dengan saya dan mengungkapkan
masalah saya.
3 G : Growth
Saya puas bahwa keluarga (teman-
teman) saya menerima & mendukung
keinginan saya untuk melakukan
aktifitas atau arah baru.
4 A : Afek
Saya puas dengan cara keluarga
(teman-teman) saya mengekspresikan
afek dan berespon terhadap emosi-emosi
saya, seperti marah, sedih atau
mencintai.

5 R : Resolve
Saya puas dengan cara teman-teman
saya dan saya menyediakan waktu
bersamasama mengekspresikan afek dan
berespon
JUMLAH
Penilaian :

Nilai : 0-3 : Disfungsi keluarga sangat tinggi

Nilai : 4-6 : Disfungsi keluarga sedang
Nilai : 7-10 Tidak ada disfungsi keluarga
Kesimpulan :
 Pengkajian kemungkinan jatuh dengan morse fall scale (MFS)

NO PENGKAJIAN SKALA NILAI KET.

1. Riwayat jatuh: apakah lansia pernah Tidak 0
jatuh dalam 3 bulan terakhir? Ya 25

2. Diagnosa sekunder: apakah lansia Tidak 0

memiliki lebih dari satu penyakit? Ya 15

3. Alat Bantu jalan:

- Bed rest/ dibantu perawat 0
- Kruk/ tongkat/ walker 15
- Berpegangan pada benda-benda di 30
sekitar (kursi, lemari, meja)
4. Terapi Intravena: apakah saat ini Tidak 0
lansia terpasang infus?
5. Gaya berjalan/ cara berpindah:
- Normal/ bed rest/ immobile (tidak 0
dapat bergerak sendiri)
- Lemah (tidak bertenaga) 10
- Gangguan/ tidak normal (pincang/ 20
diseret)
6. Status Mental
- Lansia menyadari kondisi dirinya 0
- Lansia mengalami keterbatasan daya 15
ingat
Total Nilai
 Keterangan:

Tingkatan Risiko Nilai MFS Tindakan

Tidak berisiko 0 - 24 Perawatan dasar

Risiko rendah 25 - 50 Pelaksanaan intervensi pencegahan jatuh standar

Risiko tinggi ≥ 51 Pelaksanaan intervensi pencegahan jatuh risiko tinggi

Kesimpulan :
Pengkajian resiko dekubitus dengan skala Norton

INDIKATOR TEMUAN NILAI SKOR

Baik 4
KONDISI FISIK UMUM Cukup baik 3
Buruk 2
Sangat buruk 1
Composmentis 4
KESADARAN Apatis 3
Konfus/Soporis 2
Stupor/pingsan/tidak sadar 1
Dapat berpindah 4
AKTIVITAS Berjalan dengan bantuan 3
Terbatas dikursi 2
Terbatas ditempat tidur 1
Bergerak Bebas 4
MOBILITAS Sedikit terbatas 3
Sangat terbatas 2
Tidak atau sulit bergerak 1
Tidak ngompol 4
INKONTINENSIA Kadang - kadang 3
Sering Inkontenensia Urine 2
Sering Inkontenensia Alvi dan Urine 1
Keterangan :
Skor < 14 : Resiko tinggi terjadinya ulkus decubitus
Skor < 12 : Peningkatan risiko 50x lebih besar terjadinya ulkus decubitus
Skor 12 – 13 : Resiko Sedang
Skor > 14 : Resiko Kecil
Kesimpulan :
  Pengkajian tes keseimbangan Sullivan
No Tes Koordinasi Keteranga Nilai
. n
1. Berdiri dengan postur normal

2. Berdiri dengan postur normal menutup mata

3. Berdiri dengan kaki rapat

4. Berdiri dengan satu kaki

5. Berdiri, fleksi trunk dan berdiri ke posisi netral

6. Berdiri lateral dan fleksi trunk

7. Berjalan, tempatkan tumit salah satu kaki di depan jari kaki yang
lain

8. Berjalan sepanjang garis lurus

9. Berjalan mengikuti tanda gambar pada lantai

10. Berjalan menyamping

11. Berjalan mundur

12. Berjalan mengikuti lingkaran

13. Berjalan pada tumit

14. Berjalan dengan ujung kaki

Jumlah
Keterangan
4= Mampu melakukan aktifitas dengan lengkap
3= Mampu melakukan aktifitas dengan bantuan
2= Mampu melakukan aktifitas dengan bantuan maksimal
1= Tidak mampu melakukan aktifitas
Nilai:
42-54= Mampu melakukan aktifitas
28-41= Mampu melakukan aktifitas dengan sedikit bantuan
14-27= Mampu melakukan aktifitas dengan bantuan maksimal
14 = Tidak mampu melakukan
Kesimpulan :

F. LINGKUNGAN TEMPAT TINGGAL

1. Kebersihan dan kerapian ruangan :
2. Penerangan dan sirkulasi udara :
3. Keadaan kamar mandi dan wc :
4. Pembuangan air kotor :
5. Sumber sir minum :
6. Sumber pencemaran :
7. Penataan halaman :
8. Privasi :
9. Resiko injury :

Banyuwangi, ...........................2021

Pemeriksa

(..............................................)
NIM: .......................
 ANALISA DATA

NO. DATA ETIOLOGI PROBLEM

 DIAGNOSA KEPERAWATAN

NO PRIORITAS DIAGNOSA KEPERAWATAN

1.

2.

3.

4.

Dst
.
 INTERVENSI KEPERWATAN

DIAGNOSA NAMA DAN

NOC DAN INDIKATOR URAIAN AKTIVITAS RENCANA
NO TANGGAL KEPERAWATAN TTD
SERTA SKOR AWAL DAN TINDAKAN (NIC)
DITEGAKKAN / KODE PERAWAT
SKOR TARGET
DIAGNOSA KEPERAWATAN
 IMPLEMENTASI & EVALUASI KEPERAWATAN
EVALUASI
NO DIAGNOSA IMPLEMENTASI NAMA DAN
KEPERAWATAN (PERBANDINGAN SKOR AKHIR
TERHADAP SKOR AWAL DAN SKOR TTD
DITEGAKKAN Tgl/ Jam Tindakan Keperawatan PERAWAT
/KODE DIAGNOSA TARGET)
KEPERAWATAN