Genogram
Laki – laki
Perempuan
Meninggal
Klien
Tinggal
serumah
Bercerai
Keterangan Genogram
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1. Keluhan fisik :
2. Tingkat kesadaran
£ Compos mentis £ Somnolen £ Sopor £ Apatis £ Stupor £ Koma £ Sedasi
3. GCS= E = ................ V= ................... M= .................
4. Tanda – Tanda Vital
TD : / mmHg Nadi : ............ x/m Pernafasan .......... x/m Suhu :…........ 0C
5. Penilaian Nyeri: Tidak Ya Skor Nyeri: ……………/10
£ Nyeri Kronis: Lokasi : ……..…..… Kualitas: .................... Frekuensi : …………..... Durasi …………....
£ Nyeri Akut: Lokasi : ………...… Kualitas: ................... Frekuensi : .................. Durasi ……….....…
Nyeri Hilang:
£ Minum Obat £ Istirahat £ Mendengar Musik £ Berubah Posisi Tidur £ Lainnya, sebutkan………………..
Ekspresi wajah :
BB Ideal : .................................................
SKRINING GIZI (berdasarkan Malnutrition Screening Tool / MST)
(Lingkari skor sesuai dengan jawaban, Total skor adalah jumlah skor yang dilingkari)
No Parameter Skor
1. Apakah pasien mengalami penurunan berat badan yang tidak diinginkan dalam 6 bulan terakhir?
a. Tidak penurunan berat badan 0
b. Tidak yakin / tidak tahu / terasa baju lebih longgar 2
Jika ya, berapa penurunan berat badan tersebut
1-5 kg 1
6-10 kg 2
11-15 kg 3
>15 kg 4
Tidak yakin penurunannya 2
2. Apakah asupan makan berkurang karena berkurangnya nafsu makan?
a. Tidak 0
b. Ya 1
TOTAL SKOR
3. Pasien dengan diagnosa khusus : Tidak Ya ( DM Ginjal Hati Jantung
Paru Stroke Kanker Penurunan Imunitas Geriatri Lain-lain …………….)
Bila skor ≥ 2 dan atau pasien dengan diagnosis / kondisi khusus dilakukan pengkajian lanjut oleh Tim Terapi Gizi
Sudah dilaporkan ke Tim Terapi Gizi: Tidak Ya, tanggal & jam ……………………………...........
Tidak Ya, Jika Ya, stiker risiko jatuh warna kuning harus dipasang
NO KATEGORI PENILAIAN SKOR
Ya 25
1 Riwayat Jatuh 3 bulan terakhir
Tidak 0
Memiliki lebih dari satu penyakit 15
2 Penyakit skunder
Tidak memiliki lebih dari satu penyakit 0
Bed rest/ dibantu perawat 0
3 Alat Bantu Jalan Kruk/ tongkat/ wolker 15
Berpegangan pada benda benda di sekitar (lemari/kursi/meja) 30
Ya 20
4 Terapi intravena
Tidak 0
Normal/ bed rest/ immobile (tidak dapat bergerak sendiri) 0
5 gaya berjalan / cara pindah Lemah (tidak bertenaga) 10
Gangguan/ tidak normal (pincang, diseret) 20
Menyadari kondisi dirinya sendiri 0
6 Status Mental
Lansia mengalami keterbatasan daya ingat 15
TOTAL SKOR
Skor: 0 – 24: Tidak Beresiko 25 – 50: Resiko Rendah > 50: Resiko Tinggi
VII. PSIKOSOSIAL
1. Keadaan emosi
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2. Konsep diri:
a. Gambaran diri: …………………………………………………………………………………………………....................
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b. Identitas diri:…………………………………………………………………………………………………...............….....
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c. Peran:………………………………………………………………………………………………………….....................
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d. Ideal diri:………………………………………………………………………… …………………………............…........
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e. Harga diri: ...………………………………………………………………………………………………..............……….
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3. Sosial
a. Orang yang berarti :.................................................................................................................. ..............................
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b. Dukungan keluarga ................................................................................................................................... .............
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c. Hubungan antar keluarga.......................................................................................................................................
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d. Peran serta dalam kegiatan kelompok/masyarakat .................................................................................................
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e. Hambatan dalam berhubungan dengan orang lain ..................................................................................................
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4. Spiritual dan budaya
a. Nilai dan keyakinan .......................................................................................................................................... ........
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b. Pelaksanaan ibadah ....................................................................................................................................... .......
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c. Keyakinan tentang kesehatan........................................................................................................................... .......
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d. Keyakinan terkait budaya ……………………………………………………………………………………....................
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VIII. KEBUTUHAN KOMUNIKASI DAN EDUKASI
Bahasa utama : ………………………………. Bahasa Isyarat: Tidak Ya
Dibutuhkan penerjemah : Tidak Ya, Sebutkan………… …………………………………………………………
Kesiapan untuk belajar : tinggi rendah penuh perhatian banyak bertanya
Terdapat hambatan dalam pembelajaran : Tidak Ya, Jika Ya :
Gangguan Pendengaran Penurunan Penglihatan Kapasitas Kognitif Kurang perhatian
Perbedaan Budaya Kendala Emosi Kendala Bahasa Tingkat Pendidikan
Gangguan Proses berfikir Kesulitan financial Keyakinan spiritual Lainnya
Sebutkan …………………………………………………………………………………………………………………….
XI. DIAGNOSA KEPERAWATAN (Lingkari nomor diagnosis yang anda temukan pada masalah pasien)
No Fisik No Psikososial
1 Nyeri Akut / kronik 1 Ansietas
2 Diare 2 Gangguan citra tubuh
3 Gangguan mobilisasi fisik 3 Berduka antisipatif
4 Hipertermi / Hipotermi 4 Harga diri rendah situasional
5 Intoleransi aktifitas 5 Ketidakberdayaan
6 Berat Badan Lebih 6 Keputusasaan
7 Defisit Nutrisi 7 Ketidakefektifan Koping
8 Hipervolemia 8 Ketidakmampuan Koping Keluarga
9 Hipovolemia 9 Ketidakefektifan performa peran
10 bersihan jalan nafas tidak efektif 10 Sindrome pasca trauma
11 Gangguan eliminasi urine 11 Defisit Perawatan Diri
12 Gangguan pertukaran gas 12 Nausia
13 Gangguan pola tidur 13 Defisit Pengetahuan
14 Penurunan curah jantung 14 Gangguan Rasa Nyaman
15 Pola napas tidak efektif 15 Kesiapan Peningkatan
Pengetahuan
16 Resiko infeksi
17 Resiko ketidak seimbangan cairan
18 Resiko syok
19 Resiko / konstipasi
20 Resiko jatuh
21 Resiko aspirasi
22
23
1. Pemeriksaan Laboratorium
Tanggal: ………
XIII. Penatalaksanaan :
1. Medis :
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2. Keperawatan:
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DO:
DS:
DO:
DS:
DO:
1. ........................................................................................................................................................................................ .....
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2. .............................................................................................................................................................................................
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3. ......................................................................................................................................................................................
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Ruang : ……………………………………………
No. MR : ……………………………………………
Implementasi Paraf
No. Tanggal Evaluasi SOAP
( terdapat Respon dan Hasil) perawat
1
PENGKAJIAN
MASALAH KEPERAWATAN :
1. ………………………………………………………………………......
2. ………………………………………………………………………......
3. ………………………………………………………………………......