LAPORAN KASUS

.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................

Tanggal ................................

Oleh :
_________________________
NIM ...............................

PROGRAM STUDI PENDIDIKAN PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA
TA. 2011/2012
 LEMBAR PENGESAHAN

.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................

Tanggal ................................

Oleh :
_________________________
NIM ...............................

Mengetahui, Surabaya, ................ 20.....

Penguji Pendidikan Penguji Lahan

______________________ ______________________
 PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN ANAK
STIKES HANG TUAH SURABAYA

Ruangan : ...................................................................... Tgl/jam pengkajian : ...............................

Diagnosa medis : ...................................................................... Anamnesa diperoleh dari :
No. Register : ...................................................................... 1.
Tgl/jam MRS : ...................................................................... 2. ...........

I. BIODATA
1. Identitas Anak
Nama : .................................................................................................................
Umur/tanggal lahir : .................................................................................................................
Jenis kelamin : .................................................................................................................
Agama : .................................................................................................................
Golongan darah : .................................................................................................................
Bahasa yang dipakai : .................................................................................................................
Alamat : .................................................................................................................

2. Identitas Orang Tua

Nama ayah : ................................... Nama ibu : .......................................
Umur : ................................... Umur : .......................................
Agama : ................................... Agama : .......................................
Suku/bangsa : ................................... Suku/bangsa : .......................................
Pendidikan : ................................... Pendidikan : .......................................
Pekerjaan : ................................... Pekerjaan : .......................................
Penghasilan : ................................... Penghasilan : .......................................
Alamat : ................................... Alamat : .......................................

3. Identitas Saudara Kandung

No. Nama Hubungan Status Kesehatan

II. RIWAYAT KESEHATAN

A. Riwayat Kesehatan Sekarang
1. Keluhan utama
................................................................................................................................................
................................................................................................................................................
2. Riwayat penyakit sekarang
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

B. Riwayat Kesehatan Lalu (Khusus untuk Anak Usia 0 – 5 Tahun)

1. Prenatal care
a. Ibu memeriksakan kehamilannya setiap minggu di .......................................................
b. Keluhan selama hamil yang dirasakan ibu :
.........................................................................................................................................
 .........................................................................................................................................
c. Riwayat terkena radiasi : .........................................................................................
d. Berat badan selama hamil : .........................................................................................
e. Riwayat Imunisasi TT : .........................................................................................
f. Golongan darah ibu ....................... Golongan darah ayah .........................................
2. Natal
a. Tempat melahirkan : ...................................................................................................
b. Jenis persalinan : ...................................................................................................
c. Penolong persalinan : ...................................................................................................
d. Komplikasi yang dialami oleh ibu pada saat melahirkan dan setelah melahirkan
.........................................................................................................................................
.........................................................................................................................................
3. Post natal
a. Kondisi bayi : .............................................................. APGAR ..................................
b. Kesehatan anak saat lahir
.........................................................................................................................................
.........................................................................................................................................
c. Penyakit masa kecil
.........................................................................................................................................
pada umur : ........................ diberikan obat oleh : .........................................................
d. Tindakan (operasi atau tindakan lain)
.........................................................................................................................................
.........................................................................................................................................
e. Alergi
.........................................................................................................................................
.........................................................................................................................................
f. Kecelakaan
.........................................................................................................................................
.........................................................................................................................................
g. Konsumsi obat-obatan berbahaya tanpa anjuran dokter dan penggunaan zat/subtansi
kimia yang berbahaya
.........................................................................................................................................
.........................................................................................................................................
h. Perkembangan anak dibanding saudara-saudaranya
.........................................................................................................................................
.........................................................................................................................................

C. Riwayat Kesehatan Keluarga

Genogram :

III. RIWAYAT IMUNISASI

IV.
Waktu Reaksi Setelah
No. Jenis Imunisasi Frekuensi Frekuensi
Pemberian Pemberian
1. BCG
2. DPT (I, II, III)
3. Polio (I, II, III, IV)
4. Campak
5. Hepatitis
RIWAYAT TUMBUH KEMBANG
A. Pertumbuhan Fisik
1. Berat badan : ..................... kg
2. Tinggi badan : ..................... cm
3. Tumbuh gigi : ..................... bulan Jenis gigi : ....................... Jumlah gigi........ buah.
B. Perkembangan Tiap tahap
1. Berguling : ..................... bulan
2. Duduk : ..................... bulan
3. Merangkak : ..................... bulan
4. Berdiri : ..................... tahun
5. Berjalan : ..................... tahun
6. Senyum kepada orang lain : ..................... tahun
7. Bicara pertama kali : ..................... tahun, dengan menyebutkan : ..........................
8. Berpakaian tanpa bantuan : ..................... tahun

V. RIWAYAT NUTRISI
A. Pemberian ASI
....................................................................................................................................................
....................................................................................................................................................
B. Pemberian susu formula
1. Alasan pemberian : ...............................................................................................................
2. Jumlah pemberian : ...............................................................................................................
3. Cara pemberian : ...............................................................................................................
C. Pola perubahan nutrisi tiap tahap usia sampai nutrisi saat ini
Usia Jenis Nutrisi Lama Pemberian

VI. RIWAYAT PSIKOSOSIAL

A. Anak tinggal bersama
....................................................................................... di ......................................................
B. Lingkungan berada di
....................................................................................................................................................
....................................................................................................................................................
C. Rumah dekat dengan
....................................................................................................................................................
Tempat bermain .........................................................................................................................
Kamar klien ...............................................................................................................................
D. Rumah ada tangga : ya / tidak
E. Hubungan dengan anggota keluarga
....................................................................................................................................................
....................................................................................................................................................
F. Hubungan dengan teman sebaya
....................................................................................................................................................
 ....................................................................................................................................................
G. Pengasuh anak
....................................................................................................................................................
....................................................................................................................................................

VII. RIWAYAT SPIRITUAL

A. Support sistem dalam keluarga: ................................................................................................
B. Kegiatan keagamaan : ................................................................................................
VIII. REAKSI HOSPITALISASI
A. Pengalaman keluarga tentang sakit dan rawat inap
1. Alasan Ibu membawa anak ke RS : .....................................................................................
2. Apakah dokter menceritakan tentang kondisi anak : ( ) ya ( ) tidak
3. Perasaan orang tua saat ini : .....................................................................................
4. Orang tua selalu berkunjung ke RS : ( ) ya ( ) tidak
5. Yang akan tinggal dengan anak : .....................................................................................
B. Pemahaman anak tentang sakit dan rawat inap
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

IX. AKTIVITAS SEHARI-HARI

A. Nutrisi
No. Kondisi SMRS MRS
1 Frekwensi

2 Nafsu makan

3 Jenis makanan

4 Alergi/pantangan/yang tidak disukai

B. Cairan
No. Kondisi SMRS MRS
1 Jenis minuman

2 Frekuensi minum

3 Kebutuhan cairan

4 Cara pemenuhan

C. Eliminasi
1. BAB
No. Kondisi SMRS MRS
1 Tempat pembuangan

2 Frekuensi

3 Konsistensi

4 Warna
 5 Bau

6 Kesulitan

7 Obat pencahar

2. BAK
No. Kondisi SMRS MRS
1 Tempat pembuangan

2 Frekuensi

3 Warna

4 Kesulitan

D. Istirahat tidur
No. Kondisi SMRS MRS
1 Jam tidur

a. Siang

b. Malam

2 Pola tidur

3 Kebiasaan sebelum tidur

4 Kesulitan tidur

E. Personal hygiene
No. Kondisi SMRS MRS
1 Mandi

a. Cara

b. Frekuensi

c. Alat mandi

2 Cuci rambut

a. Frekuensi

b. Cara

3 Gunting kuku

a. Frekuensi

b. Cara
 4 Gosok gigi

a. Frekuensi

b. Cara

F. Olahraga
No. Kondisi SMRS MRS
1 Program olahraga

2 Jenis

3 Frekuensi

4 Kondisi setelah olahraga

G. Aktifitas / mobilitas fisik

No. Kondisi SMRS MRS
1 Kegiatan sehari-hari

2 Pengaturan jadwal harian

3 Penggunaan alat bantu aktifitas

4 Kesulitan pergerakan tubuh

H. Rekreasi
No. Kondisi SMRS MRS
1 Perasaan saat sekolah

2 Waktu luang

3 Perasaan setelah rekreasi

4 Waktu senggang keluarga

5 Kegiatan hari libur

X. PEMERIKSAAN FISIK
A. Keadaan umum : ......................................................................................................................
B. Kesadaran : ......................................................................................................................
C. Tanda-tanda vital :
1. Tekanan darah : ................................. mmHg
2. Denyut nadi : ................................. x / menit
3. Suhu : ................................. °C
4. Pernapasan : ................................. x / menit
D. Berat Badan : .......................... kg
E. Tinggi Badan : .......................... cm
F. Kepala
 Inspeksi
Keadaan rambut & Hygiene kepala
1. Warna rambut : .....................................................................................................
2. Penyebaran : .....................................................................................................
3. Mudah rontok : .....................................................................................................
4. Kebersihan rambut : .....................................................................................................
 Palpasi
1. Benjolan : ( ) ada ( ) tidak ada
2. Nyeri tekan : ( ) ada ( ) tidak ada
3. Tekstur rambut : ( ) kasar ( ) halus
 Data lain : ............................................................................................................................
G. Muka
 Inspeksi
1. Simetris : ( ) ya ( ) tidak
2. Bentuk wajah : .....................................................................................................
3. Gerakan abnormal : .....................................................................................................
4. Ekspresi wajah : .....................................................................................................
 Palpasi
Nyeri tekan : ( ) ya ( ) tidak
 Data lain : ............................................................................................................................
H. Mata
 Inspeksi
1. Palpebra : ( ) edema ( ) radang ( ) lain-lain,..........
2. Sclera : ( ) icterus ( ) lain-lain, .....................................
3. Conjungtiva : ( ) radang ( ) anemis ( ) lain-lain,..........
4. Pupil : ( ) isokor ( ) anisokor ( ) myosis
( ) midriasis ( ) lain-lain, .....................................
5. Refleks cahaya : ( ) positif ( ) negatif
6. Posisi mata : ( ) simetris ( ) asimetris
7. Gerakan bola mata : ............................................................................................
8. Penutupan kelopak mata : ............................................................................................
9. Keadaan bulu mata : ............................................................................................
10. Keadaan visus : ............................................................................................
11. Penglihatan : ( ) kabur ( ) diplopia ( ) lain-lain,..........
 Palpasi
Tekanan bola mata : ...........................................................................................
 Data lain : ............................................................................................................................
.............................................................................................................................................
I. Hidung & Sinus
 Inspeksi
1. Posisi hidung : .......................................................................................................
2. Bentuk hidung : .......................................................................................................
3. Keadaan septum : .......................................................................................................
4. Secret / cairan : .......................................................................................................
 Data lain : ............................................................................................................................
J. Telinga
 Inspeksi
1. Posisi telinga : ............................................................................................
2. Ukuran / bentuk telinga : ............................................................................................
3. Aurikel : ............................................................................................
4. Lubang telinga : ( ) bersih ( ) serumen ( ) nanah
5. Pemakaian alat bantu : ( ) ya ( ) tidak
 Palpasi
Nyeri tekan : ( ) ya ( ) tidak
 Pemeriksaan uji pendengaran
1. Rinne : ............................................................................................
2. Weber : ............................................................................................
 3. Swabach : ............................................................................................
 Pemeriksaan vestibuler : ............................................................................................

 Data lain : ............................................................................................................................

K. Mulut
 Inspeksi
1. Gigi
a. Keadaan gigi : ............................................................................................
b. Karang gigi / karies : ( ) ya ( ) tidak
c. Pemakaian gigi palsu : ( ) ya ( ) tidak
2. Gusi : ( ) merah ( ) radang ( ) lain-lain, ...................................
3. Lidah : ( ) kotor ( ) bersih ( ) lain-lain, ...................................
4. Bibir : ( ) cianosis ( ) pucat ( ) basah ( ) kering
( ) pecah ( ) lain-lain,...................................................................

5. Mulut : ( ) berbau ( ) tidak berbau

6. Kemampuan bicara : ............................................................................................
 Data lain : ............................................................................................................................
L. Tenggorokan
1. Warna mukosa : .................................................................................................................
2. Nyeri tekan : ( ) ya ( ) tidak
3. Nyeri menelan : ( ) ya ( ) tidak
4. Data lain : .................................................................................................................
M. Leher
 Inspeksi
Kelenjar thyroid : ( ) membesar ( ) tidak ( ) lain-lain,......................
 Palpasi
1. Kelenjar thyroid : ( ) teraba ( ) tidak
2. Kaku kuduk : ( ) ya ( ) tidak
3. Kelenjar limfe : ( ) membesar ( ) tidak ( ) lain-lain,........................
 Data lain : ............................................................................................................................
N. Thorax dan pernapasan
 Inspeksi
1. Bentuk dada : ...........................................................................
2. Irama pernafasan : ...........................................................................
3. Pengembangan di waktu bernapas : ...........................................................................
4. Tipe pernapasan : ...........................................................................
 Palpasi
1. Vokal fremitus : ........................................................................................................
2. Massa / nyeri : ........................................................................................................
 Auskultasi
1. Suara nafas : ( ) vesikuler ( ) bronchial ( ) bronchovesikuler
2. Suara tambahan : ( ) ronchi ( ) wheezing ( ) rales
 Perkusi
( ) hypersonor ( ) pekak ( ) redup ( ) tympani
 Data lain : ............................................................................................................................
O. Jantung
 Palpasi
Ictus cordis : .......................................................................................................
 Perkusi
Pembesaran jantung : .......................................................................................................
 Auskultasi
( ) s1s2 tunggal ( ) murmur ( ) gallop ( ) lain-lain,.................
 Data lain : ............................................................................................................................
P. Abdomen
 Inspeksi
1. Membuncit : ( ) ya ( ) tidak
 2. Luka : ( ) ya ( ) tidak
 Palpasi
1. Hepar : ( ) teraba ( ) tidak ( ) lain-lain,........................................
2. Lien : ( ) teraba ( ) tidak ( ) lain-lain,........................................
3. Nyeri tekan : ( ) ya ( ) tidak
 Auskultasi
Peristaltik : ...............................................................................................................
 Perkusi : ( ) redup ( ) tympani
 Data lain : ............................................................................................................................
Q. Genitalia dan anus : ...................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
R. Ekstremitas
 Ekstremitas atas
1. Motorik
a. Pergerakan kanan / kiri : ..................................................................................
b. Pergerakan abnormal : ..................................................................................
c. Kekuatan otot kanan / kiri : ..................................................................................
d. Tonus otot kanan / kiri : ..................................................................................
e. Koordinasi gerak : ..................................................................................
2. Refleks
a. Biceps kanan / kiri : .......................................................................................
b. Triceps kanan / kiri : .......................................................................................
3. Sensori
a. Nyeri : ( ) ya ( ) tidak
b. Rangsang suhu : .......................................................................................

c. Rasa raba : .......................................................................................

 Ekstremitas bawah
1. Motorik
a. Gaya berjalan : .......................................................................................

b. Kekuatan kanan / kiri : .......................................................................................

c. Tonus otot kanan / kiri : .......................................................................................

2. Refleks
a. KPR kanan / kiri : .......................................................................................

b. APR kanan / kiri : .......................................................................................

c. Babinsky kanan / kiri : .......................................................................................

3. Sensori
a. Nyeri : ( ) ya ( ) tidak
b. Rangsang suhu : .......................................................................................

c. Rasa raba : .......................................................................................

 Data lain : ............................................................................................................................

S. Status Neurologi
 Penciuman : ......................................................................................................................
 Penglihatan : ......................................................................................................................
 Oculomotorius, Trochlearis, Abducens
1. Konstriksi pupil : .........................................................................
2. Gerakan kelopak mata : .........................................................................
3. Pergerakan bola mata : .........................................................................
4. Pergerakan mata ke bawah & dalam : .........................................................................
 Trigeminus
1. Sensibilitas / sensori : ................................................................................................
2. Refleks dagu : ................................................................................................
3. Refleks cornea : ................................................................................................
 Facialis
1. Gerakan mimik : .........................................................................
2. Pengecapan 2/3 lidah bagian depan : .........................................................................
 Fungsi pendengaran :
.............................................................................................................................................
: ...........................................................................................................................................
 Glosopharingeus dan Vagus
 1. Refleks menelan : ....................................................................
2. Refleks muntah : ....................................................................
3. Pengecapan 1/3 lidah bagian belakang : ....................................................................
4. Suara : ....................................................................
 Assesorius
1. Memalingkan kepala ke kiri dan ke kanan : .............................................................
2. Mengangkat bahu : .............................................................
 Hypoglossus
1. Deviasi lidah : ...................................................................................................
2. Kaku kuduk : ...................................................................................................
3. Kernig Sign : ...................................................................................................
4. Refleks Brudzinski : ...................................................................................................
5. Refleks Lasegu : ...................................................................................................
 Data lain : ............................................................................................................................

XI. TINGKAT PERKEMBANGAN (0-6 Tahun Menggunakan DDST)

A. Adaptasi Sosial
....................................................................................................................................................
....................................................................................................................................................
B. Bahasa
....................................................................................................................................................
....................................................................................................................................................
C. Motorik Halus
....................................................................................................................................................
....................................................................................................................................................
D. Motorik Kasar
....................................................................................................................................................
....................................................................................................................................................
E. Kesimpulan dan Pemeriksaan Perkembangan
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

XII. PEMERIKSAAN PENUNJANG

A. Laboratorium
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
B. Rontgen
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
C. Terapi
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

Surabaya, .....................

(...............................)
 ANALISA DATA

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. register : ..............................................

.No Data Penyebab Masalah

 PRIORITAS MASALAH

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. register : ..............................................

Tanggal Nama
No. Diagnosa Keperawatan
Ditemukan Teratasi Perawat
 RENCANA KEPERAWATAN
No. Diagnosa Keperawatan Tujuan Intervensi Rasional
 TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No. Tgl/jam Tindakan TT Tgl/jam Catatan Perkembangan TT