BAB III

ASUHAN KEPERAWATAN
A. PENGKAJIAN
1. Tanggal Pengkajian

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2. Tanggal Masuk

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3. Identitas Data

Nama

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Alamat

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Tanggal Lahir/umur: ...

Jenis Kelamin

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Agama

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Diagnosa Medis

Penanggung Jawab :

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Nama Orang Tua

Ayah

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Ibu

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Pekerjaan

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Alamat

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4. Keluhan Utama Saat Pengkajian

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5. Riwayat Penyakit Sekarang
a. Serangan
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b. Karakteristik
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c. Kondisi Yang berhubungan dengan serangan
1) Insiden
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2) Progress
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3) Efek Terapi
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6. Riwayat Masa Lalu
a. Riwayat Kehamilan
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b. Persalinan

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c. Kelahiran (BBL/PBL, waktu penambahan BBL, Kondisi Kesehatan, Apgar
Score, Kelainan kongenital, Kapan keluar dari ruang perawatan)
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d. Alergi
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e. Pertumbuhan dan Perkembangan (BBL dan sekarang, gigi, control kepala
duduk jalan kata, interaksi dengan peer)
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f. Imunisasi
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g. Kebiasaan (Perilaku, ADL)
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h. Pemeriksaan Fisik
1) Keadaan umum :............................................................................................
2) Tanda-tanda vital

HR:..RR:T:

.SP02.
3) Rambut
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4) Mata
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5) Telinga
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6) Hidung
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7) Mulut

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8) Leher
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9) Dada
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10) Abdomen
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11) Genetalia
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12) Ekstremitas
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13) Kulit
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i. Pemeriksaan Nutrisi
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j. Riwayat Kesehatan yang Lalu
1) Pohon Keluarga
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2) Penyakit
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3) Kebiasaan Keluarga

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7. Psikososial
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8. Pengetahuan Orang Tua
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9. Pemeriksaan Penunjang
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10. Terapi
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B. ANALISA DATA
No

Data Fokus

Etiologi

Problem

C. PROBLEM LIST
No

Tgl/ Jam Ditemukan

Dx Kep

Ttd

Tgl/ Jam Diatasi

Ttd

D. RENCANA ASUHAN KEPERAWATAN

No

Tgl/Jam

Dx Kep

Tujuan
Tujuan

Intervensi

Ttd

E. IMPLEMENTASI KEPERAWATAN
No

No Dx

Tgl/ Jam

Implementasi

Respon

Ttd

F. EVALUASI
No

Tgl/ Jam

Dx Keperawatan

Evaluasi

Ttd