BAB III

ASUHAN KEPERAWATAN
I. PENGKAJIAN
A. Data Demografi
1. Klien/Pasien
a.
b.
c.
d.

Tanggal pengkajian : ...................................................

Tanggal masuk
: ...................................................
Ruangan
: ...................................................
Identitas
Nama
: ...................................................
Tanggal lahir/umur: ...................................................
Jenis kelamin : ...................................................
Agama
: ...................................................
Suku
: ...................................................
No. CM
: ...................................................
Diagnosa medis
: ...................................................
Penanggung jawab: ...................................................
2. Orang Tua/ Penanggung Jawab
a. Nama
: ....................
b. Hubungan dengan klien
: ........................
c. Suku
: ........................
d. Agama
: ....................
e. Alamat
: ...............................
f. No. telepon
: .......................................
B. Keluhan Utama
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
C. Riwayat Klien
1. Riwayat penyakit klien sebelumnya

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

..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
3. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit
persalinan, dll):
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
4. Riwayat imunisasi (lengkapi)
Hepatitis B I
BCG
Hepatitis B II
Hepatitis B III
Polio I
Polio II
Polio III
Polio IV
DPT I
DPT II
DPT III
Campak
LAINNYA, sebutkan.......................................................
5. Riwayat alergi :
..........................................................................................................................
..........................................................................................................................
6. Riwayat pemakaian obat-obatan :
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
7. Riwayat tumbuh kembang (Sejak lahir hingga sekarang):
..........................................................................................................................

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

..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
D. Riwayat Kesehatan Keluarga
1. Riwayat penyakit dalam keluarga:
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
2. Genogram

Keterangan gambar :
: laki-laki
: perempuan
: tinggal dalam satu rumah

: klien
: meninggal

E. Riwayat Penyakit sekarang

1. Riwayat Penyakit Sekarang
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
2. Penampilan umum

a. 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)
....................................................................................................................
....................................................................................................................
3. Nutrisi dan cairan:
a. Nutrisi
1) Lingkar Lengan atas

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

2) Panjang badan/tinggi badan

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

3) Berat badan

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

4) Lingkar kepala

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

5) Lingkar dada

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

6) Lingkar perut

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

7) Status nutrisi (z-score atau WHO, CDC)

...............................................................................................................
...............................................................................................................
...............................................................................................................
8) Kebutuhan kalori :
...............................................................................................................
...............................................................................................................
9) Jenis makanan
...............................................................................................................
Makanan yang disukai
...............................................................................................................
Alergi makanan
...............................................................................................................
10) Kesulitan saat makan

...............................................................................................................
...............................................................................................................
11) Kebiasaan khusus saat makan
...............................................................................................................
...............................................................................................................
12) Keluhan (mual, muntah, kembung, anoreksia, dsb)
...............................................................................................................
...............................................................................................................
...............................................................................................................
b. Cairan
1) Kebutuhan cairan 24 jam: ............................jam
2) Balance cairan
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) Diuresis : ....................................................
.............................................
4) Rute cairan masuk
...............................................................................................................
...............................................................................................................
...............................................................................................................
5) Jenis Cairan
...............................................................................................................
...............................................................................................................
...............................................................................................................
6) 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)
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................

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

...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
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
1) Gambaran tubuh
...............................................................................................................
...............................................................................................................
2) Ideal diri
...............................................................................................................
...............................................................................................................
3) Harga diri
...............................................................................................................
...............................................................................................................
4) Peran diri
...............................................................................................................
...............................................................................................................
5) Identitas diri
...............................................................................................................
...............................................................................................................
g. Spiritual (kebiasaan ibadah, keyakinan, nilai, budaya)
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
h. Adakah terapi lain selain medis yang dilakukan
.....................................................................................................................
.....................................................................................................................
8. Pemeriksaan penunjang (laboratorium, radiologi)
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................

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

...........................................................................................................................
...........................................................................................................................
9. Terapi:
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
II. ANALISA DATA
Nama Klien
Usia
No. CM
No.

:
:
:
Data

Problem

Etiologi

III.PROBLEM LIST
Nama Klien
:
Usia
:
No. CM
:
Tgl/ Jam
No.
Ditemukan

Dx. Keperawatan

TTD

Tgl/ Jam Teratasi

TTD

IV. RENCANA KEPERAWATAN

V. Nama Klien :
VI. Usia
:
VII.
No. CM
VIII. IX.
Tgl/
No.
Jam
XIX. LIII.
XX.
XXI.
XXII.
XXIII.
XXIV.
XXV.
XXVI.
XXVII.
XXVIII.
XXIX.
XXX.
XXXI.
XXXII.
XXXIII.
XXXIV.
XXXV.
XXXVI.
XXXVII.
XXXVIII.
XXXIX.
XL.
XLI.

:
No

X.
. Dx
LIV.

XI.
XVI.
LV.

Tujuan

Intervensi
XVII. Tindakan
LVI.

XII.
TTD
LVII.

XLII.
XLIII.
XLIV.
XLV.
XLVI.
XLVII.
XLVIII.
XLIX.
L.
LI.
LII.
LVIII.
LIX.

IMPLEMENTASI

LX.
Nama Klien :
LXI.
Usia
:
LXII.
No. CM
:
LXIII.LXIV. No. LXV. Tgl
No.
Dx
LXIX. CIV.
LXX.
LXXI.
LXXII.
LXXIII.
LXXIV.
LXXV.
LXXVI.
LXXVII.
LXXVIII.

/ Jam
CV.

LXVI. Implementasi
CVI.

LXVII. Respon
CVII.

LXVIII.
TTD
CVIII.

LXXIX.
LXXX.
LXXXI.
LXXXII.
LXXXIII.
LXXXIV.
LXXXV.
LXXXVI.
LXXXVII.
LXXXVIII.
LXXXIX.
XC.
XCI.
XCII.
XCIII.
XCIV.
XCV.
XCVI.
XCVII.
XCVIII.
XCIX.
C.
CI.
CII.
CIII.
CIX.
CX.

EVALUASI (perkembangan setiap hari dalam bentuk SOAP)

CXI.
CXII.

Nama Klien
Usia

:
:

CXIII.
No. CM
CXIV. CXV. Tgl/
No.
Jam
CXIX.CLIV.
CXX.
CXXI.
CXXII.
CXXIII.
CXXIV.
CXXV.
CXXVI.
CXXVII.
CXXVIII.
CXXIX.
CXXX.
CXXXI.
CXXXII.
CXXXIII.
CXXXIV.
CXXXV.
CXXXVI.
CXXXVII.
CXXXVIII.
CXXXIX.
CXL.
CXLI.
CXLII.
CXLIII.
CXLIV.
CXLV.

:
CXVI. Dx. Kep
CLV.

CXVII. Evaluasi
CLVI.
CLVII.
CLVIII.
CLIX.
CLX.
CLXI.
CLXII.
CLXIII.
CLXIV.
CLXV.
CLXVI.

CXVIII.
TTD
CLXVII.

CXLVI.
CXLVII.
CXLVIII.
CXLIX.
CL.
CLI.
CLII.
CLIII.
CLXVIII.
CLXIX.