ASUHAN KEPERAWATAN PADA ANAK

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 : ...................................
Diagnosa medis : ...................................
Penanggung jawab : ..................................

2. Orang Tua/ Penanggung Jawab

a. Nama : ....
b. Hubungan dengan klien :
c. Suku : ....
d. Agama :
e. Alamat : ................................................
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f. No. telepon : ................
B. Riwayat Klien
1. Keluhan utama saat ini : ..................................................................................................
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2. Riwayat penyakit klien sebelum masuk rumah sakit :
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3. Riwayat sakit sebelumnya : .............................................................................................
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4. Riwayat kehamilan (ANC, masalah kesehatan selama kehamilan, dll) :
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5. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit
persalinan, dll):
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6. 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.......................................
7. Riwayat alergi :
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8. Riwayat pemakaian obat-obatan :
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9. Riwayat tumbuh kembang (Sejak lahir hingga sekarang):
Motorik halus:
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Motorik kasar:
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Bahasa:
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Personal sosial:
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C. 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

D. Riwayat Penyakit sekarang

1. Penampilan umum
a. Keadaan umum (kondisi klien secara 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, dll)
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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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h. Kebutuhan Kalori:
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i. Jenis makanan : .......................................................................
Makanan yang disukai : .......................................................................
Alergi makanan : .......................................................................
j. Kesulitan saat makan :
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k. Kebiasaan khusus saat makan:
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l. Keluhan (mual, muntah, kembung, anoreksia, dsb...):
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m. Balance cairan (hitung jumlah dan jenis cairan masuk dan keluar):
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 n. Diuresis :
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o. Rute cairan masuk (oral, parenteral, enteral, dsb)
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p. Jenis cairan (ASI/susu formula/infus/air putih, dsb):
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q. Keluhan :
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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):

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5. Pemeriksaan Fisik (Head to toe)
a. Keadaan Umum
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b. Kesadaran
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c. Tanda - Tanda Vital
Suhu : .................
Nadi : .................
RR : .................
SPO2 : .................
d. Kepala
1) Rambut dan Kulit kepala
Inspeksi
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Palpasi
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2) Wajah
Inspeksi
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Palpasi
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3) Mata
Inspeksi
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Palpasi
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4) Hidung
Inspeksi
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Palpasi
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5) Mulut
Inspeksi
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 Palpasi
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6) Telinga
Inspeksi
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Palpasi
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e. Leher
Inspeksi :
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Palpasi :
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f. Paru paru
Inspeksi : ....................................................................................................
Palpasi
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Perkusi : ....................................................................................................
Auskultasi : ....................................................................................................
g. Jantung.
Inspeksi : ....................................................................................................
Palpasi : ....................................................................................................
Perkusi : ....................................................................................................
Auskultasi : ....................................................................................................
h. Abdomen
Inspeksi : ....................................................................................................
Auskultasi : ....................................................................................................
Perkusi
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 Palpasi
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i. Genetalia
Inspeksi : ....................................................................................................
Palpasi : ....................................................................................................
j. Ektremitas Atas
Inspeksi
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Palpasi
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k. Ektremitas bawah
Inspeksi :
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Palpasi :
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Kekuatan Otot :
6. 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
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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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7. Pemeriksaan penunjang (laboratorium, radiologi)
8. Terapi: ....................................................................................