Format Askep Anakokbanget
Format Askep Anakokbanget
Format Askep Anakokbanget
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. Keluhan utama klien : ...................................................................................................
2. Riwayat penyakit klien sebelum masuk RS : ..............................................................
.......................................................................................................................................
3. Riwayat sakit klien sebelumnya : .................................................................................
4. Riwayat kehamilan
ANC :.....................................................................................................
masalah kesehatan selama kehamilan :.................................................................
................................................................................................................................
................................................................................................................................
..............
Lain-lain : ..............................................................................................................
................................................................................................................................
................................................................................................................................
5. Riwayat persalinan
Jenis persalinan : .................................................................................
Penolong persalinan : .........................................................................................
Apgar skor : .........................................................................................
Penyulit persalinan : .........................................................................................
6. Riwayat Imunisasi (lengkapi)
Hepatitis BI BCG
Hepatitis B II Hepatitis B II
Polio I Polio II
Polio III Polio IV
DPT I DPT II
DPT III Campak
Lainnya,sebutkan……...........................
...
7. Riwayat alergi :
……………...............................................................................................................
.......
……………...............................................................................................................
.......…………….......................................................................................................
8. Riwayat pemakaian obat-obatan:
……………...............................................................................................................
.......
……………............................................................................................................
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):
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
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