PENGKAJIAN KEPERAWATAN GERONTIK

Tanggal kajian : ………………………

A. DATA BIOGRAFI
Nama : .......................................................................................................................
Tempat & tanggal lahir : ....................................... Gol.Darah: .....................................................
Pendidikan terakhir : ........................................................................................................................
Agama : .......................................................................................................................
Status perkawinan : .......................................................................................................................
TB / BB : ...................Cm / ....................Kg
Penampilan : ..................................... Ciri-ciri tubuh :.......................................................
Alamat : .........................................................................................................................
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Telp : ......................................................................................................................
Orang dekat yang dihubungi : ......................................................................
Hubungan dengan Usila:
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Alamat: ..............................................................................................................................................................
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Telp : ........................................................................................................................

B. RIWAYAT HIDUP
Genogram :

Keterangan :

C. RIWAYAT PEKERJAAN
Pekerjaan saat ini : .........................................................................................................................
Alamat kerja : .........................................................................................................................
Berapa jarak dari rumah : .........................Km
Alat transportasi : .........................................................................................................................
Pekerjaan sebelumnya : .........................................................................................................................
Berapa jarak dari rumah : .........................Km
Alat transportasi : .........................................................................................................................
Sumber-sumber pendapatan & kecukupan terhadap kebutuhan : ......................................................................
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D. RIWAYAT LINGKUNGAN HIDUP
Tipe tempat tinggal : ......................................................................................................................................
Jumlah Kamar : ......................................................................................................................................
Kondisi tempat tinggal : ...............................................................................................
Jumlah orang yang tinggal di rumah : Laki-laki = .......orang / Perempuan = .......orang
Derajat Privasi : ................................ Tetangga Terdekat : ....................................................................
Alamat/Telepon : .......................................................................................................................................

E. RIWAYAT REKREASI
Hobi / Minat : .................................................................................................................................................
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Keanggotaan Organisasi : ................................................................................................................................
Liburan / Perjalanan : .................................................................................................................................
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F. SISTEM PENDUKUNG
Perawat / Bidan /Dokter / Fisioterapi : .......................................................................................................
Jarak dari rumah : ..........................Km
Rumah Sakit : ................................................Jaraknya : ......................Km
KliniK : ................................................Jaraknya : ......................Km
Pelayanan Kesehatan di Rumah : .....................................................................................................
Makanan yang Dihantarkan : .....................................................................................................
Perawatan Sehari-hari yang dilakukan keluarga : ..........................................................................................
Lain-lain : ......................................................................................................

G. DISKRIPSI KEKHUSUSAN
Kebiasaan ritual : ...............................................................................................................................
Yang Lainnya : ................................................................................................................................

H. STATUS KESEHATAN
Status Kesehatan umum selama setahun yang
lalu : ......................................................................................................................................................................
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Status Kesehatan umum selama 5 tahun yang
lalu : ......................................................................................................................................................................
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Keluhan
Utama : .............................................................................................................................................................
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1. Profokatif / Paliatif
: ....................................................................................................................................................................
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2. Quality / Quantity
: ....................................................................................................................................................................
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3. Region : .........................................................................................................................
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4. Severity Scale
: ....................................................................................................................................................................
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5. Timming : .........................................................................................................................
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Pemahaman & Penatalaksanaan Masalah
Kesehatan : ......................................................................................................................................................
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Obat-obatan :
No Nama Obat Dosis Keterangan

Status imunisasi (catat tanggal terbaru)

Riwayat Alergi : ........................................ (catatan agen dan reaksi spesifik)
Obat-obatan : .......................................................................................................................................
Makanan : .......................................................................................................................................
Faktor lingkungan : .......................................................................................................................................

Penyakit Yang Diderita :

Hipertensi Rheumatoid Astma Dimensia
Lain-lain : ..............................................................................................................................................................

I. AKTIVITAS HIDUP SEHARI – HARI (ADL)

Indeks Katz :A/B/C/D/E/F/G
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Oksigenasi : ......................................................................................................................................
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Cairan & Elektrolit : .....................................................................................................................................
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Nutrisi : ......................................................................................................................................
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Eliminasi : .....................................................................................................................................
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Aktivitas : .....................................................................................................................................
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Istirahat & Tidur : ......................................................................................................................................
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Personal Hygiene : .......................................................................................................................................
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Seksual : .......................................................................................................................................
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Rekreasi : .......................................................................................................................................
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Psikologis : .......................................................................................................................................
1. Presepsi Klien : .......................................................................................................................................
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2. Konsep diri : .......................................................................................................................................
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3. Emosi : .......................................................................................................................................
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4. Adaptasi : ......................................................................................................................................
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5. Mekanisme pertahanan Diri : ........................................................................................................................
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J. TINJAUAN SISTEM
Keadaaan umum : .............................................................................................
Tingkat Kesadaran : Composmentis / Apatis / Somnolen / Sopor / Coma
GCS : Eye = .......... Verbal = .......... Motorik = .......... (...........)
Tanda-tanda Vital : Nadi = .............. Temp = ..........RR = ..............TD = ............
Pemeriksaan Fisik
1. Kepala : .................................................................................................................................................... ......
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2. Mata, Telinga, Hidung : ...................................................................................................................................
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3. Mulut dan Tenggorokan: .................................................................................................................................
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4. Leher : .............................................................................................................................................................
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5. Dada:
Paru: ...................... ........................................................................................................................................
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Jantung: …………………………………………………………………………………………………………………
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6. Abdomen:
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7. Tulang Belakang: ............................................................................................................................................
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8. Ekstremitas atas & bawah : ............................................................................................................................
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9. Perkemihan: ...................................................................................................................................................
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10. Genetalia dan Anus : ......................................................................................................................................
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11. Pemeriksaan Neurologi : .................................................................................................................................
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K. STATUS KONGNITIF / AFEKTIF / SOSIAL

1. Short Portable Mental Status Questionnaire (SPMSQ):
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2. Mini Mental State Exam (MMSE):
…………………………………………………………………………………...
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3. Inventaris Depresi Beck:
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4. APGAR Keluarga:
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L. DATA PENUNJANG
1. Laboratorium : ...........................................................................................................................................
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2. Radiologi : .................................................................................................................................................
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3. EKG : .........................................................................................................................................................
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4. USG : .........................................................................................................................................................
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5. CT-Scan :
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6. Obat-obatan :

SHORT PORTABLE MENTAL STATUS QUETIONNAIRE

(SPMSQ)
(Penilaian ini untuk mengetahui fungsi intelektual manula)

Nama Klien : ……………………………………….. Tanggal : ……………………………

Jenis Kelamin : L / P Umur : …….. Tahun TB / BB : …….Cm / …… Kg
Agama : ……………... Suku : …………………….. Gol. Darah : ………
Tahun Pendidikan : ………. SD, ……….SLTP, …………SLTA, ……………PT
Alamat : ........................................................................................................
Nama Pewawancara : .........................................................................................................

Score No Pertanyaan Jawaban

1 Tanggal berapa hari ini ?
2 Hari apa sekarang ini ?
3 Apa nama tempat ini ?
4 Berapa nomor telepon Anda ?
4.a. Dimana alamat anda ?
(tanyakan bila tidak memiliki telepon)
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 dari
setiap angka baru, semua secara menurun
?
Jumlah Kesalahan Total
 INDEKS KATZ
(Indeks Kemandirian Pada Aktivitas Kehidupan Sehari-hari)

Nama Klien : ................................................ Tgl ....................................

Jenis Kelamin : L / P Umur : ..........thn TB / BB : ............ Cm / .............. Kg
Agama : ....................... Suku : ............................ Gol Darah : ..............
Tahun Pendidikan : ...............SD, ....................SLTP, .................SLTA, .................PT
Alamat : .........................................................................................................

Score Kriteria
Kemandirian dalam makan, kontinen, berpindah, ke kamar kecil, berpakaian dan
A
mandi.
Kemandirian dalam semua aktivitas hidup sehari-hari, kacuali satu dari fungsi
B
tersebut.
Kemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi dan satu
C
fungsi tambahan.
Kemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi, erpakaian
D
dan satu fungsi tambahan.
Kemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi,
E
berpakaian, ke kamar kecil dan satu fungsi tambahan.
Kemandirian dalam semua aktivitas hidup sehari-hari, kecuali mandi,
F
berpakaian, ke kamar kecil, berpindah dan satu fungsi tambahan
G Ketergantungan pada enam fungsi tersebut.
Tergantung pada sedikitnya dua fungsi, tetapi tidak dapat diklarifikasikan
Lain-lain
sebagai C, D, E atau F.
 MINI – MENTAL STATE EXAM (MMSE)
(Menguji Aspek-aspek Kognitif dari Fungsi Mental)

Nilai
Pasien Pertanyaan
maksimum
Orientasi
5 (Tahun) (Musim) (Tanggal) (Hari) (Bulan apa sekarang) ?
5 Dimana kita : (Negara bagian) (Wilayah) (Kota) Rumah Sakit) (Lantai) ?
Registrasi
Nama 3 objek : 1 detik untuk mengatakan masing-masing. Kemudian
tanyakan klien ketiga objek setalah anda mengatakannya. Beri 1 point
3 untuk 1 jawaban benar. Kemudian Ulangi sampai ia mempelajari
ketiganya. Jumlahkan percobaan dan catat.
Percobaan : ……………
Perhatikan
kalkulasi
Seri 7’s. 1 point untuk setiap kebenaran.
5
Berhenti setelah jawaban. Berganti eja “kata” kebelakang.
Mengingat
Minta untuk mengulang objek diatas.
3
Berikan 1 point untuk setiap kebenaran.
Bahasa
Nama pensil dan melihat (2 point)
9
Mengulang hal berikut : “Tak ada jika, dan, atau tetapi” (1 point)
Nilai Total

Kaji Tingkat kesadaran sepanjang Kontinum :

Composmentis Apatis Somnolen Suporus Coma

Keterangan :
Nilai maksimal 30, Nilai 21 atau kurang biasanya indikasi adanya kerusakan kognitif yang memerlukan
penyelidikan lanjut.
 APGAR KELUARGA
(Skrining Fungsi Sosial)

Nama Klien : ………………………………………………………………

Tanggal : ………………………………
Jenis Kelamin : L / P Umur : ……………thn TB / BB : ............Cm / ..........Kg
Agama : ……………. Suku ……………………… Gol Darah : ………..
Tahun Pendidikan : ………SD, ………..SLTP, ……....SLTA, …………..PT
Alamat : .............................................................................................................

No Uraian Fungsi Score

1 Saya puas bahwa saya dapat kembali pada keluarga (teman- Adaptation
teman) saya untuk membantu pada waktu sesuatu menyusahkan
saya.
2 Saya puas dengan cara keluarga (teman-teman) saya
membicarakan sesuatu dengan saya dan mengungkapkan masalah
dengan saya.
3 Saya puas bahwa keluarga (teman-teman) saya menerima dan
mendukung keinginan saya untuk melakukan aktifitas atau arah
baru.
4 Saya puas dengan cara keluarga (teman-teman) saya
mengekspresikan afek dan berespon terhadap emosi-emosi saya,
seperti marah, sedih, atau menciantai.
5 Saya puas dengan cara teman-teman saya dan saya menyediakan
waktu bersama-sama.
Penilaian :
Pertanyaan –pertanyaan yang di jawab ;
. Selalu : score 2
. Kadang-kadang : score 1
. Hampir tidak pernah : score 0
 INVENTARIS DEPRESI BECK
(Mengkaji Tingkat Depresi)

Nama Klien : ........................................................... Tgl : ..........................................

Jenis Kelamin : L / P Umur : ............thn TB / BB : .........Cm / ............Kg
Agama : ................... Suku : .................................... Gol Darah : .........
Tahun Pendidikan : ................SD, ...............SLTP, ..................SLTA, ...................PT
Alamat : ...............................................................................................................
Score Uraian
A. Kesedihan
3 Saya sangat sedih/tidak dapat bahagia dimana saya tak dapat menghadapinya
2 Saya galau/sedih sepanjang waktu dan saya tidak dapat keluar darinya
1 Saya merasa sedih atau galau
0 Saya tidak merasa sedih
B. Pesimisme
3 Saya merasa bahwa masa depan adalah sia-sia dan sesuai tidak dapat membaik
2 Saya merasa tidak mempunyai apa-apa untuk memandang ke depan
1 Saya merasa berkecil hati mengenai masa depan
0 Saya tidak begitu pesimis atau kecil hati tentang masa depan
C. Rasa Kegagalan
3 Saya merasa benar-benar gagal sebagai orangtua (suami/istri)
2 Bila melihat kehidupan kebelakang, semua yang dapat saya lihat hanya kegagalan
1 Saya merasa telah gagal melebihi orang yang pada umumnya
0 Saya tidak merasa gagal
D. Ketidak Puasan
3 Saya tidak puas dengan segalanya
2 Saya tidak lagi mendapatkan kepuasan dari apapun
1 Saya tidak menyukai cara yang saya gunakan
0 Saya tidak merasa tidak puas
E. Rasa Bersalah
3 Saya merasa seolah-olah sangat buruk atau tak berharga
2 Saya merasa sangat bersalah
1 Saya merasa buruk / tak berharga sebagai bagian dari waktu yang baik
0 Saya tidak merasa benar-benar bersalah
F. Tidak Menyukai Diri Sendiri
3 Saya benci diri saya diri sendiri
2 Saya muak dengan diri saya sendiri
1 Saya tidak suka dengan diri saya sendiri
0 Saya tidak merasa kecewa dengan diri sendiri
G. Membahayakan Diri Sendiri
3 Saya akan membunuh diri saya sendiri jika saya mempunyai kesempatan
2 Saya mempunyai rencana pasti tentang tujuan bunuhdiri
1 Saya merasa lebih baik mati
0 Saya tidak mempunyai pikiran-pikiran mengenai membahayakan diri sendiri
H. Menarik Diri Dari Sosial
3 Saya telah kehilangan semua minat saya pada orang lain dan tidak peduli pada mereka
semuanya
2 Saya telah kehilangan semua minat saya pada orang lain dan mempunyai sedikit perasaan
 kepada mereka
1 Saya kurang berminat kepada orang lain dari pada sebelumnya
0 Saya tidak kehilanganminat pada orang lain
I. Keragu-raguan
3 Saya tidak dapat membuat keputusan sama sekali
2 Saya mempunyai banyak kesulitan dalam membuat keputusan
1 Saya berusaha mengambil keputusan
0 Saya membuat keputusan yang baik
J. Perubahan Gambaran Diri
3 Saya merasa tampak jelek atau tampak menjijikan
2 Saya merasa bahwa ada perubahan-perubahan yang permanen dalam penampilan saya dan ini
membuat saya tak menarik
1 Saya khawatir bahwa saya tampak tua atau tak menarik
0 Saya tidak merasa bahwa saya merasa tampak lebih buruk dari pada sebelumnya
K. Kesulitan Kerja
3 Saya tidak melakukan pekerjaan sama sekali
2 Saya telah mendorong diri saya sendiri dengan keras untuk melakukan sesuatu
1 Saya memerlukan upaya tambahan untuk mulai melakukan sesuatu
0 Saya dapat bekerja kira-kira sebaik sebelumnya
L. Keletihan
3 Saya sangat lelah untuk melakukan sesuatu
2 Saya merasa lelah untuk melakukan sesuatu
1 Saya merasa lelah dari yang biasanya
0 Saya tidak merasa lebih lelah dari biasanya
M. Anoreksia
3 Saya tidak lagi mempunyai napsu makan sama sekali
2 Napsu makan saya sangat memburuk sekarang
1 Napsu makan saya tidak sebaik sebelumnya
0 Napsu makan saya tidak buruk dari yang biasanya
PENILAIAN
0-4 Depresi tidak ada atau minimal
5-7 Depresi ringan
8-15 Depresi sedang
16+ Depresi berat

ANALISA DATA
No Data Etiologi Problem
DS :
1.
DO :
 DIAGNOSA KEPERAWATAN
1.
2.
3.

RENCANA KEPERAWATAN
No Diagnosa Tujuan Kriteria Hasil Intervensi

TINDAKAN KEPERAWATAN
No Diagnosa Hari/ Tgl/ Jam Implementasi Paraf

EVALUASI KEPERAWATAN
No Diagnosa Hari/ Tgl/ Jam Evaluasi Paraf
S :
O :
A :
P :