PENGKAJIAN KEPERAWATAN ANAK

DATA IDENTITAS KLIEN

Nama : .................................................................................
Tempat / Tanggal lahir :..................................................................................
Nama Ayah/lbu :..................................................................................
Pekerjaan Ayah :..................................................................................
Pendidikan Ayah :..................................................................................
Pekerjaan lbu :..................................................................................
Pendidikan Ibu :..................................................................................
Alamat :..................................................................................
Kultur :..................................................................................
Agama :..................................................................................
Diagnosis Medis : ..................................................................................
Tanggal MRS : ..................................................................................
Tanggal Pengkajian : ..................................................................................

I. KELUHAN UTAMA
a. Keluhan Masuk Rumah Sakit
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
b. Keluhan Saat ini
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

II. RIWAYAT KESEHATAN

a. Riwayat penyakit sekarang:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
.....................................................................................................................................

b. Riwayat penyakit dahulu

......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
III. RIWAYAT IMUNISASI
 ......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

IV. RIWAYAT PENYAKIT KELUARGA

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

GENOGRAM

Keterangan:

RIWAYAT SOSIAL
1. Sistem pendukung/ keluarga terdekat yang dapat dihubungi
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
2. Lingkungan rumah
......................................................................................................................................
 ......................................................................................................................................
......................................................................................................................................
3. Problem sosial yang penting
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

V. KEADAAN KESEHATAN SAAT INI

1. Tindakan Operasi
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
2. Status Nutrisi
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

NCHS
a. BB/U
……………………………………………………………………………………
…………...………………………………………………………………………
b. TB/U
……………………………………………………………………………………
…………...………………………………………………………………………
c. BB/TB
……………………………………………………………………………………
……………………………………………………………………………………
d. CDC 2000
…………………………………………………………………………………
……..……………………………………………………………………………
3. Status Cairan:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
4. Aktivitas Anak
Sebelum Masuk Rumah Sakit:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
Saat Dirawat Di Rumah Sakit:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

5. Obat-Obatan
No Obat
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
Dosis
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
................................
Indikasi
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
.......................................................
.................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
....................................................
 .......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
....................................................
6. Hasil Laboratorium
Jam: Tanggal:
NILAI
PEMERIKSAAN HASIL SATUAN METODA
RUJUKAN
HEMATOLOGI
Hemoglobin 11.00-16.00 g/dl Colorimetric
Leukosit 4.65 – 10.3 ribu/ul Impedance
Eritrosit 4.00 – 5.50 Juta/ul Impedance
Analyzer
Hematokrit 32.00 – 44.00 Vol%
Calculates
Trombosit 150 – 356 Ribu/ul Impedance
Analyzer
RDW-CV 12.1 – 14.0 %
Calculates
MCV,MCM, MCHC
Analyzer
MCV 75.0-96.0 fl
Calculates
Analyzer
MCH 28.0-32.0 Pg
Calculates
Analyzer
MCHC 33.0-37.0 %
Calculates
HITUNG JENIS
Gran% 50.0-70.0 % Impedance
Limfosit% 25.0-40.0 % Impedance
MID% 4,0-11,0 % Impedance
Gran# 2.50-7.00 Ribu/ul Impedance
Limfosit# 1.25-4.0 Ribu/ul Impedance
MID# Ribu/ul Impedance
KIMIA
HATI
SGOT 0-46 U/l IFCC
SGPT 0-45 U/l IFCC
GINJAL
Ureum 10-50 mg/dl Modif-Berhelot
 Creatinin 0,6-1,2 mg/dl Jaffe

VI. PEMERIKSAAN FISIK

1. Keadaan Umum:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
2. Kesadaran : .......................................................................................................
- Tanda Vital : .......................................................................................................
- Nadi : x/ menit
- Suhu : °C
- RR : x/ menit
3. Pengkajian Skala Nyeri
 ....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
4. Kepala dan Leher
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

5. Mata
Posisi bola mata : ...........................................................................................
Gerakan mata : ...............................................................................................
Konjungtiva : .............................................................................................................
Kornea : .....................................................................................................................
Sklera : ......................................................................................................................
Pupil :.........................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

6. THT
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
7. Ekstremitas
 ....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
8. Toraks
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
9. Jantung
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
10. Abdomen
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
11. Genitalia
Frekuensi BAK: ......................../hari , Jumlah Urine: ........................ cc
Warna Urine: .............................................................................................................
Penggunaan Alat bantu berkemih: ............................................................................
Kondisi Blast: ............................................................................................................
Tanggal defekasi terakhir: .........................................................................................
Frekuensi BAB: .........../hari, Konsistensi: ..............., Warna: ......................
Penggunaan Alat bantu (Laksatif): ............................................................................
12.Tumbuh Kembang
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
 ANALISIS DATA
Nama Klien : ..............................................
Umur : ..............................................
Ruangan/Kamar : ..............................................
No. Data Penyebab Masalah
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
 PRIORITAS MASALAH
Nama klien : ..............................................
Umur : ..............................................
Ruangan/kamar : ..............................................
No. RM : ..............................................
Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama Perawat)
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ..................................
........................................................................ ......................................... ......................................... ................

No. Diagnosa Keperawatan
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
RENCANA KEPERAWATAN
Tujuan Dan
Kriteria Hasil
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
Intervensi
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
Rasional
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.................................................... ....
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
................................................
....................................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
..........................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
............................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.................................................... ....
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
................................................
.........................................................
....................................................
 IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN
No.
Waktu
Dx Implementasi
Tgl/jam
Kep
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
Waktu
TT Evaluasi TT
Tgl/jam
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................