FORMAT PENGKAJIAN PADA LANSIA

Tanggal Pengkajian :
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A. DATA BIOGRAFI
Nama :
Tempat dan Tanggal Lahir :
Pendidikan terakhir :
Agama :
Status Perkawinan :
TB/BB :
Penampilan :
Alamat :
Orang yang dekat dihubungi :
Hubungan dengan usila :
Alamat :

B. RIWAYAT GENOGRAM
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C. RIWAYAT PEKERJAAN
Pekerjaan sebelumnya :
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Alamat pekerjaan :
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Berapa jarak dari rumah :
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Alat transportasi :
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Sumber – sumber pendapatan yang lain :
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D. RIWAYAT LINGKUNGAN HIDUP

Tipe tempat tinggal :
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Jumlah kamar :
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Kondisi tempat tinggal :
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Jumlah orang yang tinggal di rumah :
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Alamat / no. telepon :
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E. RIWAYAT REKREASI
Hobbi / minat :
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Keanggotaan organisasi :
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F. SISTEM PENDUKUNG
Perawat /bidan /dokter /fisioterapi :
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Jarak dari rumah :
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Rumah sakit :
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Jaraknya :
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Perawatan sehari – hari yang dilakukan oleh keluarga :
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Lain-lain :
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G. DISKRIPSI KEKHUSUSAN
Kebiasaan ritual :
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Yang lainnya :
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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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Pemahaman dan penatalaksanaan masalah kesehatan :
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I. AKTIVITAS HIDUP SEHARI – HARI

Oksigenasi :
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Cairan dan elektrolit :
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Nutrisi :
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Eliminasi :
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Aktifitas :
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Istirahat/tidur :
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Personal hygiene :
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Psikologis :
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Persepsi klien :
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Konsep diri :
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Emosi :
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Adaptasi :
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Mekanisme pertahanan diri :
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J. TINJAUAN SISTEM
Keadaan umum :
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Tingkat kesadaran :
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Tanda – tanda vital :
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Kepala
a. Bentuk kepala :
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Ubun-ubun :
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Kulit kepala :
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Rambut :
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Penyebaran dan keadaan rambut :
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Bau :
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Warna :
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b. Wajah :
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Warna kulit :
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Struktur wajah :
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Mata,telinga,hidung
Mata :
a. Kelengkapan dan kesimetrisan :
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b. Kelopak mata (palpebra) :
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c. Konjungtiva dan sclera :
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 d. Pupil :
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e. Kornea dan iris :

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f. Ketajaman penglihatan/visus :
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g. Tekanan bola mata :
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Telinga :
a. Bentuk telinga :
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Ukuran telinga :
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Ketegangan telinga :
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b. Lubang telinga :
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c. Ketajaman pendengaran :
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Hidung
a. Tulang hidung dan posisi septum nasi :
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b. Lubang hidung :
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c. Cuping hidung :
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Leher
a. Posisi trachea :
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b. Tiroid :
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c. Suara :
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d. Kelenjar limfe :
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e. Vena jugularis :
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f. Denyut nadi karotis :
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Dada dan punggung
a. Bentuk dada :
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b. Pernapasan
Frekuensi :
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Irama :
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c. Tanda-tanda kesulitan bernapas :
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d. Punggung :
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Ekstermitas atas dan bawah

a. Kesimetrisan otot :
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b. Pemeriksaan oedem :
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c. Kekuatan otot :
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d. Kelainan-kelainan pada ekstremitas :
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Genetalia
1. Genetalia
a. Rambut pubis :
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b. Meatus urethra :
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c. Kelainan-kelainan pada genetalia eksterna dan daerah inguinal :
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2. Anus dan perineum

a. Lubang anus :
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b. Kelainan-kelainan pada anus :
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c. Perineum :
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System persyarafan
a. Tingkat kesadaran (secara kuantitatif)/GCS :
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b. Tanda-tanda rangsangan otak :
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c. Syaraf otak (Nervus Cranialis)
N.I :
N.II :
N.III :
N.IV :
N.V :
N. VI :
N.VII :
N.VIII :
N.IX :
 N.X :
N.XI :
N.XII :
Sistem pengecapan :
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Sistem penciuman :
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Tactil respon :
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K. STATUS KOGNITIF/AFEKTIF/SOSIAL
1. SPMSQ :
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2. MMSE :
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3. INVENTARIS DEPRESI BACK :
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4. APGAR KELUARGA :
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5. INDEKS KATZ :
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L. DATA PENUNJANG
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(……………………………………………..)

INDEKS KATZ
( INDEKS KEMANDIRIAN PADA AKTIVITAS SEHARI – HARI )

SCORE KRITERIA
A KEMANDIRIAN DALAM HAL MAKAN, KONTINEN,
 BERPINDAH, KE KAMAR KECIL, BERPAKAIAN DAN MANDI
KEMANDIRIAN DALAM SEMUA AKTIVITAS SEHARI – HARI,
B
KECUALI SATU DARI FUNGSI TERSEBUT
KEMANDIRIAN DALAM SEMUA AKTIVITAS, KECUALI
C
MANDI DAN SATU FUNGSI TAMBAHAN
KEMANDIRIAN DALAM SEMUA AKTIVITAS, KECUALI
D
MANDI, BERPAKAIAN, DAN SATU FUNGSI TAMBAHAN
KEMANDIRIAN DALAM SEMUA AKTIVITAS, KECUALI
E MANDI, BERPAKAIAN, KE KAMAR KECIL DAN SATU FUNGSI
TAMBAHAN
KEMANDIRIAN DALAM SEMUA AKTIVITAS SEHARI – HARI,
F KECUALI MANDI, BERPAKAIAN, KE KAMAR KECIL,
BERPINDAH DAN SATU FUNGSI TAMBAHAN
G KETERANGAN PADA KE ENAM FUNGSI TERSEBUT
TERGANTUNG PADA SEDIKITNYA 2 FUNGSI, TETAPI TIDAK
LAIN – LAIN
DAPAT DIKLASIFIKASIKAN SEBAGAI C, D, E, ATAU F

SHORT PORTABLE MENTAL STATUS QUESTIONAIRE

(SPMSQ)
( PENILAIAN INI UNTUK MENGETAHUI FUNGSI INTELEKTUAL MANULA)

SKORE
NO PERTANYAAN JAWABAN
0 1
1 TANGGAL BERAPA HARI INI ?
2 HARI APA SEKARANG ?
3 APA NAMA TEMPAT INI ?
4 BERAPA NO TELP ANDA ?
4A, DIMANA ALAMAT ANDA ?
(TANYAKAN BILA TAK ADA
NO TELP).
5 BERAPA UMUR ANDA ?
 6 KAPAN ANDA LAHIR ?
7 SIAPA PRESIDEN INDONESIA
SEKARANG ?
8 SIAPA PRESIDEN
SEBALUMNYA ?
9 SIAPA NAMA KECIL IBU
ANDA ?
10 KURANGI 3 DARI 20 DAN
TETAP PENGURANGAN 3 DARI
SETIAP ANGKA BARU SEMUA
SECARA MENURUN ?
JUMLAH KESALAHAN TOTAL

KETERANGAN :
1. KESALAHAN 0 -2 : FUNGSI INTELEKTUAL UTUH
2. KESALAHAN 3 – 4 : KERUSAKAN INTELEKTUAL RINGAN
3. KESALAHAN 5 – 7 : KERUSAKAN INTELEKTUAL
SEDANG
4. KESALAHAN 8 – 10 : KERUSAKAN INTELEKTUAL BERAT
 MINI MENTAL STATE EXAM ( MMSE )

Nilai Pasien Pernyataan

Maksimum
Orientasi
5 (tahun), (musim),(tanggal), (hari), (bulan apa sekarang)
5 Dimana kita (propinsi),(wilayah),(kota),(rumah sakit),
(lantai)
Regristrasi
3 Nama 3 obyek: 1 detik untuk masing – masing kemudian
tanyakan klien ketiga obyek setelah anda telah
mengatakannya beri 1 poin untuk setiap jawaban yang
benar kemudian ulangi sampai ia mempelajari ketiganya,
jumlahkan percobaan dan catat
Perhatikan dan kalkulasi
5 Seri 7,1 poin untuk setiap kebenaran berhenti setelah 5
jawaban
Mengingat
3 Minta untuk mengulangi tiga obyek diatas
Bahasa
9 Nama pensil dan melihat ( 2 poin )
Mengulang hal berikut : tak ada jika, dan atau tetap ( 1
 poin )
Nilai total
(MENGUJI ASPEK KOGNITIF DARI FUNGSI MENTAL )

KUISONER TINGKAT DEPRESI

JAWABLAH PERTANYAAN DIBAWAH INI DENGAN MEMBERIKAN TANDA (√) PADA
JAWABAN YA/TIDAK DENGAN YANG ANDA RASAKAN

JAWABAN
NO PERTANYAAN
YA TIDAK
1 APAKAH ANDA PUAS DENGAN KEDIDUPAN ANDA ?
2 APAKAH SAAT INI ANDA SUDAH KEHILANGAN BERAKTIVITAS
DAN MINAT-MINAT ANDA ?
3 APAKAH ANDA MERASA HIDUP ANDA KOSONG ?
4 APAKAH ANDA SERING MERASA BOSAN ?
5 APAKAH ANDA SELALU SEMANGAT ??
6 APAKAH ANDA TAKUT BAHWA SUATU HAL YANG BURUK AKAN
MENIMPA ANDA
7 APAKAH ANDA MERASA GEMBIRA DALAM SEBAGAIAN BESAR
WAKTU ANDA ?
8 APAKAH ANDA SERING MERASA TIDAK ADA YANG BISA
MEMBANTU ?
9 APAKAH ANDA LEBIH TIDAK SUKA TINGGAL DIRUMAH,
DARIPADA KELUAR DAN MENGERJAKAN SESUATU HAL YANG
BARU ?
10 APAKAH ANDA BERFIKIR BAHWA ANDA MENGALAMI
GANGGUAN INGATAN LEBIH PARAH DARIPADA ORANG LAIN ?
11 APAKAH ANDA BERFIKIR BAHWA TETAP HIDUP SAAT INI
MERUPAKAN HAL YANG SANGAT MENYENANGKAN ?
12 APAKAH ANDA BERFIKIR BAHWA SAAT INI ANDA BENAR –
BENAR TIDAK BAHAGIA ?
13 APAKAH ANDA MERASA DIRI ANDA PENUH ENERGI?
14 APAKAH ANDA MERASA BAHWA KEADAAN ANDA SAAT INI
SUDAH TIDAK ADA HARAPAN ?
15 APAKAH ANDA BERFIKIR BAHWA SEBAGAIAN BESAR ORANG
LEBIH BAIK DARIPADA DIRI ANDA SENDIRI ?
KUNCI JAWABAN KOESIONER TINGKAT DEPRESI

NO JAWABAN
1 TIDAK
2 YA
3 YA
4 YA
5 TIDAK
6 YA
7 TIDAK
8 YA
9 YA
10 YA
11 TIDAK
12 YA
13 TIDAK
14 YA
15 YA

0–5 : SUSPECT DEPRESI

6 – 15 : DEPRESI

APGAR KELUARGA
ALAT SIRINING SINGKAT YANG DI GUNAKAN UNTUK MENGKAJI FUNGSI SOSIAL

NO URAIAN FUNGSI SKORE

1 SAYA PUAS KARENA SAYA DAPAT KEMBALI ADAPTATION
DENGAN KELUARGA (TEMAN-TEMAN) SAYA
UNTUK MEMBANTU PADA WAKTU SESUATU
 MENYUSAHKAN SAYA
2 SAYA PUAS DENGAN CARA KELUARGA PARTNERSHIP
(TEMAN-TEMAN) SAYA MEMBICARAKAN
SESUATU DENGAN SAYA DAN
MENGUNGKAPKAN MASALAH DENGAN
SAYA
3 SAYA PUAS DENGAN KELUARGA (TEMAN- GROWTH
TEMAN) SAYA MENERIMA DAN MENDUKUNG
KEINGINAN SAYA UNTUK MELAKUKAN
AKTIVITAS ATAU ARAH BARU
4 SAYA PUAS DENGAN CARA KELUARGA AFFECTION
(TEMAN-TEMAN) SAYA MENGEPRESIKAN
EFEK DAN BERESPON TERHADAP EMOSI
SAYA, SEPERTI MARAH, SEDIH ATAU
MENCINTAI
5 SAYA PUAS DENGAN CARA (TEMAN-TEMAN) RESOLVE
SAYA DAN SAYA MENYEDIAKAN WAKTU
BERSAMA – SAMA
PENILAIAN TOTAL
PERTANYAAN – PERTANYAAN YANG
DIJAWAB :
 SELALU : SKORE 2
 KADANG2 : SKORE 1
 HAMPIR TIDAK PERNAH : SKORE 0