BAB III

ASUHAN KEPERAWATAN
I. PENGKAJIAN
A. Data Demografi
1. Klien/Pasien
a. Tanggal pengkajian : ...................................................
b. Tanggal masuk : ...................................................
c. Ruangan : ...................................................
d. 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
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C. Riwayat Klien
1. Riwayat penyakit klien sebelumnya :
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2. Riwayat kehamilan (ANC, masalah kesehatan selama kehamilan, dll):
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3. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor,
penyulit persalinan, dll):
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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 :
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6. Riwayat pemakaian obat-obatan :
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7. Riwayat tumbuh kembang (Sejak lahir hingga sekarang):
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D. Riwayat Kesehatan Keluarga
1. Riwayat penyakit dalam keluarga:
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2. Genogram

Keterangan gambar :
 : laki-laki : klien
: perempuan : meninggal
: tinggal dalam satu rumah
E. Riwayat Penyakit sekarang
1. Riwayat Penyakit Sekarang
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2. Penampilan umum
a. Keadaan umum
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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)
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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)
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8) Kebutuhan kalori :
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9) Jenis makanan
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Makanan yang disukai
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Alergi makanan
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10) Kesulitan saat makan
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11) Kebiasaan khusus saat makan
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12) Keluhan (mual, muntah, kembung, anoreksia, dsb)
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b. Cairan
1) Kebutuhan cairan 24 jam: ............................jam
2) Balance cairan
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3) Diuresis : .................................................................................................
4) Rute cairan masuk
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5) Jenis Cairan
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6) Keluhan
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4. Istirahat tidur
a. Lama waktu tidur (24 jam) : jam
b. Kualitas tidur : ..........................................................
c. Tidur siang (ya/tidak) : .........................................................
d. Kebiasaan sebelum tidur :
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5. Pengkajian nyeri (sesuai usia, lampirkan alat ukur):
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6. Pemeriksaan Fisik (Head to toe)
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7. Psikososial anak dan keluarga
a. Respon hospitalisasi (rewel, tenang)
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b. Kecemasan (anak dan orang tua)
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c. Koping klien/keluarga dalam menghadapi masalah
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d. Pengetahuan orang tua tentang penyakit anak
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e. Keterlibatan orang tua dalam perawatan anak
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 f. Konsep diri
1) Gambaran tubuh
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2) Ideal diri
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3) Harga diri
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4) Peran diri
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5) Identitas diri
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g. Spiritual (kebiasaan ibadah, keyakinan, nilai, budaya)
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h. Adakah terapi lain selain medis yang dilakukan
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8. Pemeriksaan penunjang (laboratorium, radiologi)
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 9. Terapi:
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II. ANALISA DATA
Nama Klien :
Usia :
No. CM :
No. Data Problem Etiologi
III. PROBLEM LIST
Nama Klien :
Usia :
No. CM :
Tgl/ Jam
No. Dx. Keperawatan TTD Tgl/ Jam Teratasi TTD
Ditemukan
IV. RENCANA KEPERAWATAN
Nama Klien :
Usia :
No. CM :
Intervensi
No. Tgl/ Jam No. Dx TTD
Tujuan Tindakan
V. IMPLEMENTASI
Nama Klien :
Usia :
No. CM :
No. No. Dx Tgl/ Jam Implementasi Respon TTD
VI. EVALUASI (perkembangan setiap hari dalam bentuk SOAP)
Nama Klien :
Usia :
No. CM :
No. Tgl/ Jam Dx. Kep Evaluasi TTD