ASUHAN KEPERAWATAN PADA ANAK .......DENGAN ........................

DI RUANG PEDIATRIC INTENSIVE CARE UNIT

Tanggal Pengkajian ............................................

I. IDENTITAS
A. Data Pasien
Nama : ......................................................................
Tempat Tanggal Lahir : ......................................................................
Umur : ......................................................................
No. Rekam Medis : ......................................................................
Diagnosis Medis : ......................................................................

B. Data Penanggung Jawab

Nama Ayah/ Nama Ibu : ......................................................................
Pendidikan terakhir Ayah : ......................................................................
Pekerjaan ayah : ......................................................................
Pendidikan terakhir Ibu : ......................................................................
Pekerjaan Ibu : ......................................................................
Alamat : ......................................................................
Kultur : ......................................................................
Agama : ......................................................................

II. RIWAYAT PENYAKIT

A. Keluhan Utama
Alasan Masuk Rumah Sakit:
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Keluhan Saat Ini:
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Pediatric PSIK FK ULM®

 B. Riwayat Penyakit Sekarang
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C. Riwayat Penyakit Dahulu
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III. RIWAYAT KESEHATAN KELUARGA

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A. Genogram
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Pediatric PSIK FK ULM®

IV. PEMERIKSAAN FISIK
A. Keadaan Umum anak .........................................................
B. Tingkat Kesadaran : .................................. GCS ……………………
C. Tanda- tanda vital
Temperatur ........................... Pulse .................................
Respirasi ............................ TD ..................................
SpO2 ............................
D. Pemeriksaan Skala Nyeri

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E. Pemeriksaan B1 breath (Pernafasan)
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F. Pemeriksaan B2 blood (Kardiovaskuler)
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Pediatric PSIK FK ULM®

 G. Pemeriksaan B3 brain (Persyarafan)
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H. Pemeriksaan B4 bladder (Perkemihan)
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I. Pemeriksaan B5 bowel (Pencernaan)
Penilaian Nausea dengan Menggunakan Barf Scale
(Baxter Animated Retching Faces Scale)

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Pediatric PSIK FK ULM®
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J. Pemeriksaan B6 bone (Muskuloskeletal dan Integumen)
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V. OBAT-OBATAN (Dengan Fomat Tabel)
No Obat Dosis Indikasi
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Pediatric PSIK FK ULM®

VI. PEMERIKSAAN PENUNJANG
Pemeriksaan Hasil Nilai Normal Satuan
HEMATOLOGI
Hemoglobin ................. 10.00-17.00 g/dl
Lekosit ................. 4.0-10.5 ribu/ul
Eritrosit ................. 3.40-5.50 juta/ul
Hematokrit ................. 35.00-50.00 vol%
Trombosit ................. 150-450 ribu/ul
RDW-CV ................. 11.5-14.7 %
MCV,MCH, MCHC
MCV ................. 80.0 – 97.00 fl
MCH ................. 27.0 – 32.0 pg
MCHC ................. 32.0 – 38.0 %
HITUNG JENIS
Gran% ................. 50.0 – 70.0 %
Limfosit% ................. 25.0 – 40.0 %
MID% ................. 4.0-11.0 %
Gran# ................. 2.50 – 7.00 ribu/ul
Limfosit# ................. 1.25-4.0 ribu/ul
MID# ................. ribu/ul
KIMIA DARAH
Glukosa Darah Sewaktu ................. <200 mg/dl
HATI
SGOT ................. 0-46 u/l
SGPT ................. 0-45 u/l
GINJAL
Ureum ................. 10-50 mg/dl
Kreatinin ................. 0.7-1.4 mg/dl
ELEKTROLIT
Natrium ................. 135-146 mmol/l
Kalium ................. 3.4-5.4 mmol/l
Chlorida ................. 95-100 mmol/l

Pediatric PSIK FK ULM®

 Keterangan
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Pediatric PSIK FK ULM®

VII. PEMERIKSAAN BRADEN Q SCALE
(Pengkajian Terhadap Kejadian Luka Tekan Pada Anak di Ruang PICU)
MODIFIKASI SKALA BRADEN Q UNTUK ANAK
KOMPONEN KONDISI SKOR
Mobilitas (Mobility) Skor 4: No Limitations (Tidak ada
Definisi: Kemampuan keterbatasan gerak)
pasien secara mandiri Melakukan perubahan posisi tubuh
untuk merubah atau utama secara rutin tanpa bantuan.
mengontrol posisi Skor 3: Slightly limited (Gerakan sendi
tubuhnya terbatas)
Dapat bergerak secara rutin, tetapi
hanya sedikit perubahan posisi tubuh
atau ekstremitas yang dapat dilakukan
secara mandiri.
Skor 2: Very Limied (Sangat Terbatas)
Jarang bergerak atau merubah posisi
tubuh atau ekstremitas. Dapat merubah
posisi tubuh atau ekstremitas tetapi
tidak dapat kembali pada posisi semula
secara mandiri.
Skor 1: Completely Immobile (Tidak
dapat bergerak)
Tidak dapat merubah posisi rubuh atau
eksttremitas tanpa bantuan
Aktivitas (Activity) Skor 4: No limitations (Tidak ada
Definisi: keterbatasan)
Menggambarkan derajat Semua pasien yang usianya terlalu
akttivitas fisik pasien muda untuk melakukan ambulasi atau
saat ini. dapat berjalan dengan lancar.
Skor 3: Walks Occasionally (Dapat
berjlan tetapi terbatas atau jarang)
Dapat berjalan tetapi dengan jarak yang
sangat pendek, dengan atau tanpa
bantuan. Pasien menghabiskan
sebagian besar waktunya ditempat tidur
atau kursi
Skor 2: Chairfast (Kemampuan untuk
berjlan sangan terbatas atau bahkan
tidak dapat berjalan)
Tidak dapat menyangga berat tubuhnya
dan atau harus dibantu unuk berpindah
ke kursi atau kursi roda.
Skor 1: Bedfast
Bedrest total di tempat tidur.
Sensori Persepsi Skor 4: No Impairment (Tidak ada
(Sensory Perception) gangguan)
Definisi: Kemampuan Berespon terhadap perintah verbal,
Pediatric PSIK FK ULM®
 pasien untuk merspon tidak mengalami defisit sensori yang
ketidaknyamanan akibat membatasi kemampuan untuk
tekanan dengan cara merasakan atau mengkomunikasikan
yang tepat berdasarkan nyeri atau ketidaknyamanan.
tingkat Skor 3: Slightly limited (Sedikit
perkembangannya. terbatas)
Berespon terhadap perintah verbal
tetapi tidak dapat selalu
mengkomunikasikan ketidaknyamanan
atau mengalami beberapa gangguan
sensori yang membatasi keampuan
untuk merasakan nyeri atau
ketidaknyamanan pada satu atau dua
ekstremitas.
Skor 2: Very limited (Sangat terbatas)
Berespon hanya terhadap stimulus yang
menyakitkan. Tidak dapat
mengkomunikasikan ketidaknyamanan
kecuali dengan ekspresi wajah
kesakitan atau kelelahan atau
mengalami gangguan sensori yang
membatasi kemampuan untuk
merasakan nyeri atau ketidaknyamanan
setengah badan.
Skor 1: Completely limited (Tidak
berespon)
Tidak ada ekspresi wajah, refleks, atau
terkejut terhadap stimulus yang
menyakitkan akibat penurunan tingkat
kesadaran atau sedasi atau terbatasnya
kemampuan untuk merasakan nyeri di
seluruh permukaan tubuh.
Kelembaban Skor 4: Rarely moist (Kulit lebih
(Moisture) sering dalam keadaan kering)
Definisi: Terpaparnya Penggantian diaper secara rutin, linen
kulit pasien oleh hanya butuh diganti setiap 24 jam.
kelembaban di area Skor 3: Occasionally moist (Kulit
tonjolon tulang. tidak terlalu lembab)
Penggantian linen setiap 12 jam.
Skor 2: Very Moist (Kulit Seringkali
lembab tetapi tidak selalu lembab)
Linen harus diganti setidaknya setiap 8
jam.
Skor 1: Contantly moist (Kulitnya
selalu dalam keadaan lembab)
Kulit selalu lembab karena perspirasi,
urine, drainase, dll. Setiap pasien
didapati dalam keadaan basah.
Pediatric PSIK FK ULM®
 Gesekan dan Robekan Skor 4: No apparent problem
(Friction-Shear Pasien mampu untuk merubah posisi,
Friction) bergerak atau merubah posisi di tempat
Definisi: Gesekan tidur atau kursi secara mandiri dan
terjadi ketika kulit memiliki kekuatan otot yang baik untuk
pasien bergerak mengangkat tubuh selama bergerak
melawan permukaan, atau berpindah, serta dapat
sedangkan robekan mempertahankan posisi yang baik di
terjadi ketika kulit dan tempat tidur atau kursi.
permukaan tulangSkor 3: Potential problem
bergerak berlawanan Pasien mampu bergerak secara
satu sama lain. perlahan atau membutuhkan bantuan
minimum. Selama bergerak, kulit
mungkin bergesekan dengan linen,
kursi, restrain, dan benda lainnya.
Skor 2: Problem
Membutuhkan bantuan sedang sampai
bantuan penuh untuk
bergerak/berpindah. Seringkali merosot
dari tempat tidur atau kursi,
membutuhkan reposisi berkala dengan
bantuan total.
Skor 1: Significant probllemI
Spastisitas, kontraktur, dan agitasi
menyebabkan gesekan dan penekanan.
Nutrisi (Nutrition) Skor 4: Excellent
Definisi: Menilai Normal diet memberikan kalori yang
kebiasaan pola intake adekuat sesuai dengan usia, tidak
makanan pernah menolak untuk makan, biasanya
menghabiskan makanan yang
disediakan. Pasien tidak membutuhkan
suplemen.
Skor 3: Adequate
Pasien mendapatkan nutrisi melalui
naso/orogastric tube atau total
parenteral nurition (TPN), yang
menyediakan kalori dan mineral secara
adekuat sesuai dengan usia atau
menghabiskan separuh dari semua
porsi yang disediakan. Kadang-kdang
menolak makan dan biasanya
mengkonsumsi suplemen makanan.
Skor 2: Inadequate
Pasien mendapat diit cair atau
naso/orogastric tube/TPN, yang
menyediakan kalori dan mineral
adekuat sesuai usiaa ataau albumin
kurang dari 3mg/dl atau jarang
Pediatric PSIK FK ULM®
 menghabiskan makanan yang
disediakan. Pasien biasanya
mendapatkan uplemen makanan.
Skor 1: Very poor
NPO (Nil per Osi) dan/atau
dipertahankan untuk mendapatkan
clear liquid, atau cairan intravena lebih
dari 5 hari atau albumin kurang dari
2,5mg/dl atau tidak pernah
menghabiskan makanan. Jarang sekali
menghabiskan ½ porsi makanan yang
disediakan. Intake minum buruk. Tidak
mendapatkan tambahan makanaan cair.
Perfusi jaringan dan Skor 4: Excellent
Oksigenasi (Tissue Kondisi pasien ada dalam normotensi,
Perfusion and saturasi oksigen lebih besar dari 95%,
Oxygenation) hemoglobin normal, capillary refil <
Definisi: dari 2 detik.
Mendeskripsikan status Skor 3: Adequate
perfusi jaringan dan Kondisi pasien ada dala normotensi,
oksigenasi pasien. saturasi oksigen mungkin kurang dari
95% atau hemoglobin mungkin kurang
dari 10mg/dl atau capillary refil lebih
dari 2 deti, pH darah normal.
Skor 2: Compromised
Kondsi pasien ada dalam normotensi,
saturasi oksigen kurang dari 95% atau
hemoglobin kurang dari 10mg/dl atau
capillary refil lebih dari 2 detik, pH
darah normal.
Skor 1: Extremely compromised
Kondisi pasien ada dalam hipotensi
(mean arterial pressure < 50 mmHg,
<40 mmHg pada bayi baru lahir) atau
pasien secara fisiologi tidak dapat
entolerasi perubahan posisi.

Keterangan:
Total Skor Intepretasi
16 - 23 Pasien dengan risiko rendah
13 - 15 Pasien dengan risiko sedang
10 - 12 Paasien dengan risiko tinggi
≤9 Pasien dengan risiko sangat tinggi

Pediatric PSIK FK ULM®

 ANALISIS DATA
Nama Klien : ..............................................

Umur : ..............................................

Ruangan/Kamar : ..............................................

No. Data Penyebab Masalah

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Pediatric PSIK FK ULM®


Nama klien : ..............................................
Umur : ..............................................
Ruangan/kamar : ..............................................
No. RM : .............................................
No. Masalah Keperawatan
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Pediatric PSIK FK ULM®
PRIORITAS MASALAH
Tanggal
Ditemukan
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Paraf
(Nama Perawat)
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No. Diagnosa Keperawatan
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Pediatric PSIK FK ULM®
RENCANA KEPERAWATAN
Tujuan Dan
Kriteria Hasil
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Intervensi Rasional
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Pediatric PSIK FK ULM®
 IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN

No.
Waktu Waktu
Dx Implementasi TT Evaluasi TT
Tgl/jam Tgl/jam
Kep

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Pediatric PSIK FK ULM®

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Pediatric PSIK FK ULM®

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Pediatric PSIK FK ULM®

Pediatric PSIK FK ULM®