Asuhan Keperawatan Gerontik

ASUHAN KEPERAWATAN GERONTIK PADA
NY. D
DENGAN REUMATIK DI SUB UNIT
PERLINDUNGAN SOSIAL
TRESNA WERDHA SUKMA RAHARJA
A. PENGKAJIAN
1. Identitas Klien
Nama
: Ny. D
Umur
: 80 tahun
Jenis Kelamin
: Perempuan
Suku
: Betawi
Agama
: Islam
Pendidikan
: SPR
Status Perkawinan
: Menikah (Janda)
Tanggal Pengkajian
: 06 Mei 2010
Alamat
: Depok
2. Status Kesehatan Saat ini
Ny. D mengatakan kaki kanannya merasa pegal,
linu dan kesemutan. Hal itu dirasakan oleh Ny. D
sejak 6 bulan terakhir. Rasa kesemutan dan linu
bertambah ketika Ny. D selesai mencuci pakaian
atau mencuci piring, serta terlalu lama
melakukan aktivitas.
3. Riwayat Kesehatan Dahulu
Ny. D mengatakan tidak memiliki riwayat
penyakit apapun.
4. Riwayat Kesehatan Keluarga
Ny. D mengatakan suaminya tidak memilki

riwayat penyakit apapun.
5. Pemeriksaan Tanda-tanda Vital
Tekanan darah
: 130/80 mmHg
Nadi
: 86 kali/menit
Suhu
: 36.0 oC
Respirasi
: 20 kali/menit
Berat badan
: 50kg
6. Pemeriksaan Fisik
1. Keadaan umum
Keadaan Ny. D tampak sehat dan tampak
memegangi kaki kanannya.
2. Kepala, wajah, mata, leher
Bentuk kepala tampak bulat, tidak ada lesi dan
benjolan, rambut tampak beruban, rambut lurus
Sklera tidak ikterik, konjungtiva tidak anemis,
pupil isokhor, mata kanan tampak sering berair,
pergerakan bola mata simetris
Tidak teraba ada pembesaran kelenjar getah
bening
Hidung tampak simetris, tidak tampak ada cairan
berlebih
3. Sistem pernapasan
Bentuk thorax simetris, tidak tampak ada
retraksi intercostal, vocal premitus merata di
semua lapang paru, perkusi
terdengar resonance, auskultasi terdengar
vesikular
4. Sistem kardiovaskuler
Perkusi jantung terdengar pekak, irama jantung
terdengar regular.
5. Sistem Gastrointestinal
Tampak tidak ada lesi dan tidak ada benjolan,
bising usus terdengar 8x/menit, perkusi
terdengar tymphani.
6. Sistem urinaria
Ny. D BAK 5-6 kali sehari, tidak sakit saat BAK
dan lancar.
7. Sistem muskulosceletal
Kedua kaki dan tangan Ny. D tampak sejajar
dan sama besar dan panjang, tampak adanya
scoliosis. Kemampuan
mengubah posisi baik, pergerakan kedua tangan
dan kaik baik, kekuatan otot baik, tetapi kaki
kanan sering merasa linu dan
kesemutan.
8. Sistem syaraf pusat
Tidak ada cedera kepala, tidak ada peningkatan
TIK, tidak memiliki riwayat kejang
9. Sistem endokrin
Ny. D mengatakan tidak mempunyai penyakit
gula dan gondok.
10. Sistem reproduksi
Ny. D mengatakan pernah menikah 2 kali dan

dikaruniai 2 anak tetapi sudah meninggal sejak
kecil.
11. Sistem integument
Kulit tampak keriput, warna kulit sawo matang,
tampak ada lesi, elastisitas kulit berkuang.
12. Sistem hemopoetik
7. Pengkajian Psikososial & Spiritual
Psikososial
Ny. D mengatakan dapat bersosialisasi dengan
penghuni panti yang lainnya. Status emosi Ny. D
stabil dan kooperatif saat
diajak bicara,
sikap klien terhadap penghuni panti lainnya baik.
2. Spiritual
Ny. D beragama Islam, dan mengatakan selalu
menjalankan ibadah sholat lima waktu. Selain itu
juga mengikuti pengajian
minggguan
yang diadakan di panti.
8. Pengkajian Fungsional Klien
Katz index
No.
Kegiatan
Mandiri
1.
Mandi
2.
Berpakaian
3.
Ke Kamar Kecil
4.
Berpindah Tempat
5.
BAK/BAB
6.
Makan/Minum
Bantuan Sebagia
Ny. D dapat beraktivitas secara mandiri tanpa

pengawasan, pengarahan, atau bantuan aktif
dari orang lain.
2. Barthel index
No.
Kegiatan
Dengan Bantuan
1.
Makan/Minum
2.
Berpindah dari kursi roda ke tempat tidur/sebaliknya
3.
Kebersihan diri (cuci muka, gosok gigi, menyisir rambut)
Keluara masuk kamar mandi (menyeka tubuh, menyiram, mencuci baju)
5.
Mandi
6.
Jalan-jalan di permukaan datar
7.
Naik turun tangga
8.
Memakai baju
9.
Kontrol BAK
10.
Kontrol BAB
Jumlah
Kesimpulan:
Jumlah skor 100 = mandiri
9. Pengkajian Status Mental
Short Portable Mental Status Questioner
(SPSMQ)
Benar
Salah
No.
Pertanyaan
1.
Tanggal berapa hari ini?
2.
Hari apa sekarang?
3.
Apa nama tempat ini?
4.
Dimana alamat anda?
5.
Berapa umur anda?
6.
Kapan anda lahir?
7.
Siapa presiden Indonesia sekarang?
8.
Siapa presiden Indonesia sebelumnya?
9.
Siapa nama ibu anda?
10.
Kurangi 3 dari 20 & tetap pengurangan 3 dari setiap angka bar
10
Jumlah
Total Skor:
Salah: 4
Benar: 6
Hasil:
Salah 4-5 : kerusakan intelektual ringan
10. Pengkajian Aspek Kognitif Dari Fungsi
Mental
No.
Aspek Kognitif
Nilai Mhs
Nilai Klien
Kriteria
1.
Orientasi
Menyebutkan de
2.
Orientasi
Tahun
Musim
Tangg
Hari
Bulan
Menyebutkan de
Negara
Propin
Kota
Panti
3.
Registrasi
Pemeriksa meng
kemudian klien m
Objek
Objek

4.
Perhatian & Kalkulasi
Minta klien untu

dikurangi 7 samp
5.
Mengingat
Objek
100
93
86
79
72
Minta klien untu

objek pada no.2
Objek
Objek
Objek
6.
Bahasa
Tunjukkan pada
namanya!
Objek
Objek
Minta klie
kata beri
Tak ad
Dan a
Tetapi
(bila ben
Minta klie
perintah
Ambil
Lipat d
Taruh
Perintahk
hal berik
perintah
Tutup
Perintahk
satu kali
gambar:
Tulis s
Menya
Total Nilai
23
Interpretasi hasil :
Nilai 8-22
fungsi mental ringan
ANALISA DATA
= kerusakan aspek
No.
Data Senjang
Kemungkinan Penyebab
1.
DS:
Proses menua
Ny T mengatakan sudah dua

tahun merasa kesemutan dan
linu pada kakinya
Ny T mengatakan rasa kesemutan
dan linu bertambah jika terkena
dingin dan berkurang setelah
minum obat.
DO:
TD :130/90 mmHg
Nadi : 80 x/menit
Suhu : 36 C
Respirasi : 24 x/menit
Perubahan hormonal
Permukaan tulang dan

sendi tidak lagi licin
Tulang mengalami gesek
Nyeri
Ny T tampak memegangi kakinya

2.
DS:
Proses menua
Ny T mengatakan tidak
mengerti tentang
Penurunan daya ingat
penyakit rematik,
makanan pantangan dan Kurang terpapar informa

cara pengobatan untuk
rematik
Kurang pengetahuan
DO:
tentang rematik
Ny T tampak bertanya
tentang rematik,
makanan pantangan dan
cara pengobatan rematik
C. DIAGNOSA KEPERAWATAN
Nyeri akut akibat proses inflamasi pada daerah
kaki b.d kesemutan dan rasa ngilu pada
persendian
Kurang pengetahuan tentang rematik
berhubungan dengan keterbatasan kognitif
D. RENCANA INTERVENSI KEPERAWATAN
Tgl
No.
Dx
Diagnosa Keperawatan
Rencana
Tujuan
06 Mei 1.
2010
Nyeri akut akibat proses

Tupan:
inflamasi pada daerah kaki b.d
kesemutan dan rasa ngilu padaNyeri
persendian
Kriteria Hasil
Setelah dilakukan
intervensi hasil yang
diharapkan:
Intervensi
anjurkan kl
hilang
mandi ai
dan proses Ny D melaporkan kompres
DS:
rasa kesemutan yang sak
inflamasi
Ny D mengatakan
dan ngilu
kompres
dapat
diatasi
sudah dua tahun
berkurang
berikan ma
Tupen :
merasa kesemutan Rasa

Ny D dapat
lembut
dan linu pada
kesemutan beraktifitas ajarkan tekn
kakinya
tanpa rasa ngilu dan distr
dan ngilu
Ny D mengatakan
dan kesemutan.
kolaborasi
berkurang/
rasa kesemutan dan
kaji keluhan yang sesuai in
linu bertambah jika teratasi.
dirasakan klien, diberikan
terkena dingin dan
catat faktor
berkurang setelah
yang
minum obat
mempercepat
dan tanda-tanda
DO:
rasa sakit non
TD :130/80 mmHg
verbal.
Nadi : 86 x/menit
Suhu : 36,0 C
Respirasi : 20 x/menit
Ny D tampak
memegangi
kakinya
Tgl
No.
Dx
06 Mei 2.
2010
Diagnosa Keperawatan
Kurang pengetahuan tentang

rematik b.d keterbatasan
kognitif
DS:
Ny D
Rencana
Tujuan
Kriteria Hasil
In
Tupan : Pengetahuan Ny D
tentang rematik adekuat
Setelah dilakukan intervensi

Kaj
diharapkan:
p
Ny D mengatakan
Tupen :
paham mengenai Ber
Pengetahuan
k
penyakitnya
Ny D
c
m
Eva
p
Me
m
in
mengatakan
bertambah
tidak mengerti
tentang
penyakit
rematik,
makanan
pantangan dan
cara
pengobatan
untuk rematik
DO:
Ny D tampak
bertanya
tentang
rematik,
makanan
pantangan dan
cara
pengobatan
tradisional
untuk rematik
E. IMPLEMENTASI DAN EVALUASI
Tanggal
No.
06 Mei 2010
Implementasi
Evaluasi
Membina hubungan saling percaya S :

Ny D mengatakan
dengan klien
tahun merasa k
Mengkaji keluhan yang dirasakan

linu pada kakin
klien, catat faktor yang
Ny D mengatakan
mempercepat dan tanda-tanda rasa kesemutan dan
sakit non verbal.
jika terkena din
Menganjurkan klien untuk mandi air berkurang sete
hangat, kompres sendi- sendi yang O :
sakit dengan kompres hangat
TD :130/80 mmH
Mengajarkan teknik relaksasi dan Nadi : 86 x/menit
distraksi
Suhu : 36,0 C
Berkolaborasi pemberian obat sesuaiRespirasi : 20 x/m
indikasi yang diberikan
Ny D tampak me
kakinya
s
Ny D tampak me
teknik relaksas
nafas dalam
A:
Masalah ter
P:
Lanjutkan in
Kaji pengeahuan
penyakit remat
Berikan penkes te
rematik
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1 Response to "ASUHAN
KEPERAWATAN GERONTIK
DENGAN REUMATIK"
1 | Asuhan Keperawatan NANDA
June 10, 2012 at 7:16 pm
artikel yang bagus

kalau bisa ditambahkan diagnosa NANDA ya
terima kasih.
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Asuhan Keperawatan Gerontik

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ASUHAN KEPERAWATAN GERONTIK PADA

Ny. D mengatakan suaminya tidak memilki

Ny. D mengatakan pernah menikah 2 kali dan

Ny. D dapat beraktivitas secara mandiri tanpa

Berpindah dari kursi roda ke tempat tidur/sebaliknya

Kebersihan diri (cuci muka, gosok gigi, menyisir rambut)

Keluara masuk kamar mandi (menyeka tubuh, menyiram, mencuci baju)

Jalan-jalan di permukaan datar

Naik turun tangga

Tanggal berapa hari ini?

Hari apa sekarang?

Apa nama tempat ini?

Dimana alamat anda?

Berapa umur anda?

Kapan anda lahir?

Siapa presiden Indonesia sekarang?

Siapa presiden Indonesia sebelumnya?

Siapa nama ibu anda?

Kurangi 3 dari 20 & tetap pengurangan 3 dari setiap angka bar

Perhatian & Kalkulasi

Minta klien untu

Minta klien untu

Ny T mengatakan sudah dua

Permukaan tulang dan

Tulang mengalami gesek

Ny T tampak memegangi kakinya

makanan pantangan dan Kurang terpapar informa

Nyeri akut akibat proses

merasa kesemutan Rasa

Kurang pengetahuan tentang

Setelah dilakukan intervensi

Membina hubungan saling percaya S :

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