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BAB III

ASUHAN KEPERAWATAN

PENGKAJIAN
A. Data Demografi
1. Klien/Pasien
Tanggal pengkajian : ...................................
Tanggal masuk : ...................................
Ruangan : ...................................
Identitas
a. Nama : .......................................................................................
b. Tanggal lahir/umur : .........................................................................................
c. Jenis kelamin : ..........................................................................................
d. Agama : .........................................................................................
e. Suku : .........................................................................................
f. Diagnosa medis : .........................................................................................
g. Penanggung jawab : ..........................................................................................
2. Orang Tua/ Penanggung Jawab
a. Nama : ........................................................................................
b. Hubungan dengan klien :
c. Suku : ........................................................................................
d. Agama : ........................................................................................
e. Alamat : ........................................................................................
f. No. telepon : ........................................................................................

B. 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):
Motorik halus :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Motorik kasar :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Bahasa :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Personal sosial :
..........................................................................................................................................
..........................................................................................................................................
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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
a. Keadaan umum (kondisi klien secara umum) :

.
b. Pemeriksaaan Tanda-Tanda Vital
1) Pernapasan : ....................
2) Suhu : .....................
3) Nadi : .....................
4) Tekanan Darah: ...................
5) Saturasi oksigen: ..................
c. Penggunaan alat bantu napas (Oksigen, 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): ..................
...
...
...
h. Kebutuhan Kalori : .........................................................................
i. Jenis makanan : ............................................................................
Makanan yang disukai :................................................................
Alergi makanan : ...........................................................................
j. Kesulitan saat makan : ..........................................................................
k. Kebiasaan khusus saat makan :
.............................................................................................................................
l. Keluhan (mual, muntah, kembung, anoreksia, dsb) :
..................................................................................................................................
..................................................................................................................................
m. Kebutuhan cairan 24 jam :
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
n. Balance cairan (hitung jumlah dan jenis cairan masuk dan keluar):
..................................................................................................................................
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..................................................................................................................................
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o. Diuresis :
..................................................................................................................................
..................................................................................................................................
p. Rute cairan masuk (oral, parenteral, enteral, dsb)
..................................................................................................................................
q. Jenis cairan (ASI/susu formula/infus/air putih, dsb):
..................................................................................................................................
..................................................................................................................................
r. Keluhan :
..................................................................................................................................
..................................................................................................................................
3. Istirahat tidur
a. Lama waktu tidur (24 jam) : jam
b. Kualitas tidur : ..........................
c. Tidur siang (ya/tidak) :
d. Kebiasaan sebelum tidur : ..........................................
4. Pengkajian nyeri (sesuai usia, lampirkan alat ukur):
5. Pemeriksaan Fisik (Head to toe)
a. Keadaan umum
........................................................................................................................
........................................................................................................................
b. Kesadaran
Tingkat Respon Respon
Respon mata Nilai GCS
kesadaran motorik verbal

c. Vital sign
Capillary
Tanggal TD Nadi RR Suhu
refill

d. Kepala

Inspeksi

Palpasi

e. Mata

Inspeksi

Palpasi
f. Hidung

Inspeksi

Palpasi

g. Mulut

Inspeksi

Palpasi

h. Telinga

Inspeksi

Palpasi
i. Leher
Inspeksi

Palpasi

j. Paru-paru

Inspeksi

Palpasi

Perkusi

Auskultasi

k. Jantung

Inspeksi
Palpasi

Perkusi

Auskultasi

l. Abdomen
Inspeksi

Auskultasi

Perkusi

Palpasi
m. Genitalia
Inspeksi

n. Ekstremitas atas
Kanan Kiri
Baal Nyeri Edema Lemas Baal Nyeri Edema Lemas

Kekuatan otot : Kiri ( ), Kanan ( )


o. Ekstremitas bawah
Kanan Kiri
Baal Nyeri Edema Lemas Baal Nyeri Edema Lemas

Kekuatan otot : Kiri ( ), Kanan ( )


6. 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 :
..........................................................................................................................
.........................................................................................................................
g. Spiritual (kebiasaan ibadah, keyakinan, nilai, budaya) :
..........................................................................................................................
.........................................................................................................................
h. Adakah terapi lain selain medis yang dilakukan :
..........................................................................................................................
.........................................................................................................................
7. Pemeriksaan penunjang (laboratorium, radiologi)
Tanggal Pemeriksaan Hasil Nilai Rujukan Satuan
8. Terapi :
Jenis Terapi Dosis Rute Indikasi Kontra Indikasi Efek Samping
ANALISA DATA
NO DATA PROBLEM ETIOLOGI
PROBLEM LIST
TGL/JAM TGL/JAM
NO DX KEP TTD TTD
DITEMUKAN TERATASI
RENCANA KEPERAWATAN
TGL INTERVENSI
NO DX KEP
/JAM TUJUAN TINDAKAN TTD
IMPLEMENTASI
TGL
NO DX KEP IMPLEMENTASI RESPON TTD
/JAM
EVALUASI
NO TGL/JAM DX KEP EVALUASI TTD