ASUHAN KEPERAWATAN PADA ANAK

DENGAN KASUS .
DI RUANG ISMAIL II (BANGSAL ANAK)
RS ROEMANI

I. PENGKAJIAN
A. Data Demografi
Klien/Pasien
a. Tanggal pengkajian

: ......................................................................................................

b. Tanggal masuk

: ......................................................................................................

c. Ruangan

: ......................................................................................................

d. Identitas
Nama

: ......................................................................................................

Tanggal lahir/umur

: ......................................................................................................

Jenis kelamin

: ......................................................................................................

Agama

: ......................................................................................................

Suku

: ......................................................................................................

Diagnosa medis

: ......................................................................................................

Penanggung jawab

: ......................................................................................................

Orang Tua/ Penanggung Jawab

a. Nama

: .......................................................................

b. Hubungan dengan klien : ...........................................................................

c. Suku

: ...........................................................................

d. Agama

: .......................................................................

e. Alamat

: ...................................................................................

f. No. telepon

: ...........................................................................................

B. Riwayat Klien
Riwayat penyakit klien sebelumnya :
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................

Riwayat kehamilan (ANC, masalah kesehatan selama kehamilan, dll):

................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
1. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit persalinan, dll):
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
2. Riwayat imunisasi (lengkapi)
Hepatitis B

BCG

Hepatitis B II

Hepatitis B III

Polio I

Polio II

Polio III

Polio IV

DPT I

DPT II

DPT III

Campak

LAINNYA,sebutkan.......................................................
3. Riwayat alergi :
...........................................................................................................................................................
4. Riwayat pemakaian obat-obatan :
...................................................................................................................................................
5. Riwayat tumbuh kembang (Sejak lahir hingga sekarang):
Motorik halus:
...........................................................................................................................................................
...........................................................................................................................................................
Motorik kasar:
...........................................................................................................................................................
...........................................................................................................................................................
Bahasa:
...........................................................................................................................................................
...........................................................................................................................................................

Personal sosial:
...........................................................................................................................................................
...........................................................................................................................................................
Reflek primitif (Neonatus)
...........................................................................................................................................................
...........................................................................................................................................................

C. Riwayat Kesehatan Keluarga

1. Riwayat penyakit dalam keluarga:
...............................................................................
...............................
...........................................................................................................................................................
2. Genogram

Keterangan gambar :
: laki-laki
: klien
: perempuan

:::::

: meninggal
: tinggal dalam satu rumah

D. Riwayat Penyakit sekarang

1. Penampilan umum
Keadaan umum
...........................................................................................................
...........................................................................................................................................................
b. Pemeriksaaan Tanda-Tanda Vital
1) Pernapasan

: ...........................

2) Suhu

: ...........................

3) Nadi

: ...........................

4) Tekanan Darah

: ...........................

5) Saturasi oksigen

: ...........................

c. Penggunaan alat bantu napas (Oksigen, CPAP, dll)

......................................................................................................................................................
......................................................................................................................................................

2. Nutrisi dan cairan:

a. Lingkar Lengan atas

: .................cm

b. Panjang badan/tinggi badan : ................cm

c. Berat badan

: .................kg

d. Lingkar kepala : ................ cm

e. Lingkar dada : ................... cm
f. Lingkar perut : ....................cm
g. Status nutrisi (z-score atau WHO, CDC):
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......................................................................................................................................................
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......................................................................................................................................................
Kebutuhan kalori :
......................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
h. Jenis makanan: ............................................................................................................................
Makanan yang disukai:
......................................................................................................................................................
......................................................................................................................................................
Alergi makanan

......................................................................................................................................................
......................................................................................................................................................
i. Kesulitan saat makan :
......................................................................................................................................................
......................................................................................................................................................

j. Kebiasaan khusus saat makan :

......................................................................................................................................................
.....................................................................................................................................................
k. Keluhan (mual, muntah, kembung, anoreksia, dsb
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

3. Kebutuhan cairan 24 jam:............................................

a. Balance cairan (hitung jumlah dan jenis cairan masuk dan keluar):
1) Nilai Balance Cairan
a. IWL

Intake

No

Jenis

Output

Jumlah

Jenis

1.

Minum

BAK

2.

Makan

Muntah

3.

Infus

IWL
Feses (1x/ hari)

Jumlah

Balance Cairan = Intake Output

=
=

Jumlah

Jumlah

b. Diuresis :
......................................................................................................................................................
......................................................................................................................................................
c. Rute cairan masuk (oral, parenteral, enteral, dsb)
......................................................................................................................................................
......................................................................................................................................................
d. Jenis cairan (ASI/susu formula/infus/air putih, dsb):
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
e. Keluhan:
......................................................................................................................................................
......................................................................................................................................................

4. Istirahat tidur
a. Lama waktu tidur (24 jam)

: . jam

b. Kualitas tidur

: ..................................................................................................

c. Tidur siang (ya/tidak)

: ...................................................................................................

d. Kebiasaan sebelum tidur

: ...................................................................................................

5. Pengkajian nyeri (sesuai usia, lampirkan alat ukur):

...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................

6. Pemeriksaan Fisik (Head to toe)

a. Kepala
Inspeksi

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

Palpasi

...............................................................................................................................

...............................................................................................................................
...............................................................................................................................

b. Mata
Inspeksi

...................................................................................................................
...................................................................................................................
...................................................................................................................

Palpasi

...................................................................................................................
...................................................................................................................
...................................................................................................................

c. Hidung
Inspeksi

...................................................................................................................
...................................................................................................................
...................................................................................................................

Palpasi

...................................................................................................................
...................................................................................................................
...................................................................................................................

d. Telinga
Inspeksi

...................................................................................................................
...................................................................................................................
...................................................................................................................

Palpasi

...................................................................................................................
...................................................................................................................
...................................................................................................................

e. Mulut
Inspeksi

...................................................................................................................
...................................................................................................................
..................................................................................................................

Palpasi

...................................................................................................................
...................................................................................................................
...................................................................................................................

f. Leher
Inspeksi

...................................................................................................................
...................................................................................................................
...................................................................................................................

Palpasi

...................................................................................................................
...................................................................................................................
...................................................................................................................

g. Dada
1. Paru-paru
Paru-paru

Keterangan

Inspeksi

..........................................................................................................
..........................................................................................................
..........................................................................................................

Palpasi

..........................................................................................................
..........................................................................................................
..........................................................................................................

Perkusi

..........................................................................................................
..........................................................................................................
..........................................................................................................

Auskultasi

..........................................................................................................
..........................................................................................................
..........................................................................................................

2. Jantung
Jantung

Keterangan

Inspeksi

..........................................................................................................
..........................................................................................................
..........................................................................................................

Palpasi

..........................................................................................................
..........................................................................................................
..........................................................................................................

Perkusi

..........................................................................................................
..........................................................................................................
..........................................................................................................

Auskultasi

..........................................................................................................
..........................................................................................................
..........................................................................................................

3. Abdomen
Abdomen

Keterangan

Inspeksi

..........................................................................................................
..........................................................................................................
..........................................................................................................

Auskultasi

..........................................................................................................
..........................................................................................................
..........................................................................................................

Palpasi

..........................................................................................................
..........................................................................................................
..........................................................................................................

Perkusi

..........................................................................................................
..........................................................................................................
..........................................................................................................

h. Kulit
Inspeksi

.............................................................................................................
.............................................................................................................
....................................................................................................

Palpasi

.............................................................................................................
.............................................................................................................
....................................................................................................

i. Genitalia
Inspeksi

.............................................................................................................
.............................................................................................................
....................................................................................................

Palpasi

.............................................................................................................
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j. Ekstremitas
..............................................................................................................................................
..............................................................................................................................................
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Kekuatan otot :

7. Psikososial anak dan keluarga

a. Respon hospitalisasi (rewel, tenang):
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
b. Kecemasan (anak dan orang tua)
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
c. Koping klien/keluarga dalam menghadapi masalah
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
d. Pengetahuan orang tua tentang penyakit anak
......................................................................................................................................................
......................................................................................................................................................
e. Keterlibatan orang tua dalam perawatan anak
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
f. Konsep diri
Gambaran tubuh
......................................................................................................................................................
......................................................................................................................................................
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Ideal diri
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Harga diri
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

Peran
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Identitas diri
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
g. Spiritual (kebiasaan ibadah, keyakinan, nilai, budaya)
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
h. Adakah terapi lain selain medis yang dilakukan
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

8. Pemeriksaan penunjang (laboratorium, radiologi)

Nama test

Hasil

Flag

Unit

Nilai rujukan

Nama test

Hasil

Flag

Unit

Nilai rujukan

9. Terapi:
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
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10. ANALISA DATA

NO

DATA

PROBLEM

ETIOLOGI

11.
NO

TABEL DIAGNOSA KEPERAWATAN

TGL/JAM

DX

DITEMUKAN

KEP

TTD

TGL/JAM
TERATASI

TTD

12.
NO

RENCANA KEPERAWATAN

TGL
/JAM

DX KEP

INTERVENSI
TUJUAN

TINDAKAN

TTD

13.

IMPLEMENTASI

NO DX.KEP TGL /JAM

IMPLEMENTASI

RESPON

TTD

14.

EVALUASI

(perkembangan setiap hari dalam bentuk SOAP

NO

TGL/JAM

DX KEP

EVALUASI

TTD