ASUHAN KEPERAWATAN PADA PASIEN………..........

DENGAN .............................................................................................
DI .........................................................................................
TANGGAL............s/d………………….........

OLEH :
NAMA : A. A.ISTRI CAHYADININGRUM
NIM : P07120016039

KEMENTERIAN KESEHATAN
POLITEKNIK KESEHATAN DENPASAR
DIPLOMA III KEPERAWATAN
TAHUN 2018
 ASUHAN KEPERAWATAN PADA PASIEN.............................
DENGAN.................................................................................................
DI RUANG ........................................ - RSUD ............................................
TANGGAL............................s/d.................................................

I. IDENTITAS
A. Anak
1. Nama : …………………………………………………
2. Anak yang ke : …………………………………………………
3. Tanggal lahir/umur: ………………………………………………..
4. Jenis kelamin : …………………………………………………
5. Agama : …………………………………………………
B. Orang tua
1. Ayah
a. Nama :
…………………………………………………(kandung/tiri)
b. Umur : …………………………………………………
c. Pekerjaan : …………………………………………………
d. Pendidikan : …………………………………………………
e. Agama : ………………………………………………..
f. Alamat : …………………………………………………
2. Ibu
a. Nama :
…………………………………………………(kandung/tiri)
b. Umur : …………………………………………………
c. Pekerjaan : …………………………………………………
d. Pendidikan : …………………………………………………
e. Agama : …………………………………………………
f. Alamat : …………………………………………………
II. GENOGRAM ( dibuat apabila ada hubungan dengan kasus yang dibuat )
III. ALASAN DIRAWAT
a) Keluhan Utama :
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b) Riwayat Penyakit :
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IV. RIWAYAT ANAK (0 – 6 TAHUN), tergantung penyakit
A. Perawatan dalam masa kandungan :
Dilakukan pemeriksaan kehamilan/tidak. ........................................................
Berapa kali ………………Kapan …………………………………............. ..
Tempat di ……………………………………............................................ ....
Kesan pemeriksaan tentang kehamilan ……………………….... ...................
Obat-obat yang telah diminum …………………………………....................
Imunisasi ………………………………................................................... ......
Pemeriksaan lain …………………………………….................................... .
Penyakit yang pernah diderita ibu....................................................................
Penyakit dalam keluarga ………………………………………………..... ....

B. Perawatan pada waktu kelahiran :

Umur kehamilan …………………dilahirkan di …..................................... ...
Ditolong oleh ………………………………………………… ......................
Berlangsungnya kelahiran (biasa/susah/dengan tindakan).................... .........
Lamanya proses persalinan……………………………………………..... .....
Keadaan bayi setelah lahir …………………………………………….. ........
BB lahir …………PBL ……………LK/LD ………………………… ..........

V. KEBUTUHAN BIO-PSIKO-SOSIAL-SPIRITUAL DALAM KEHIDUPAN

SEHARI-HARI
A. Bernafas
1. Kesulitan bernafas : ada/tidak
2. Kesulitan dirasakan : menarik/mengeluarkan nafas
3. Keluhan yang dirasa :.................................................................................
4. Suara nafas : ...............................................................................................
B. Makan dan minum
Bayi
ASI/PASI : .......................................................................................................
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 (Berapa kali, pengenceran, sampai umur berapa, alasan)
Makanan pendamping ASI : ............................................................................
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Makanan cair (air buah/sari buah) diberi umur ………………………...........
Bubur susu diberi umur ……………………………………................. ..........
Nasi tim saring diberi umur ………………………………….............. ..........
Nasi tim diberi umur ……………………………………….................. .........
Makanan tambahan lainnya ……………….. .................................................
..........................................................................................................................
..........................................................................................................................
diberi umur..................... ..................................................................................
Pola makan (berapa kali sehari/selang-seling ASI). ........................................
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Anak-anak
Keadaan sebelum sakit (nafsu makan, berapa kali sehari, jenis makanan
pokok, jenis lauk, jenis sayuran, jenis buah, makanan pantang, kebiasaan
makan termasuk cara menyajikan makanan, jenis makanan selingan, kebiasaan
jajan) ……................................................………………………………… ...
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Keaadan saat sakit bagaimana ………………………………………… ........
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C. Eliminasi (BAB/BAK)
Bias memberitahu / tidak, melakukan sendiri/ditolong, tempat bab/bak,
frekuensi, warna, bau, konsistensi, kelainan
…………………………………………………………………………..........
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D. Aktifitas
Permainan
Suka bermain (ya/tidak), permainan yang disukai,
Mainan yang dimiliki, teman bermain
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E. Rekreasi
Pernah / jarang / kadang-kadang, jenis rekreasi
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F. Istirahat dan tidur

Kebiasaan istirahat.
Kebiasaan tidur : (mencuci kaki sebelum tidur, kencing sebelum tidur,
mengompol, mengorok, mengigau, sering terjaga, kebiasaan tidur yang lain
ada/tidak, tidur malam mulai jam berapa, bangun pagi jam berapa, tidur
sendiri/ditemani. Biasa tidur siang/tidak, berapa jam
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G. Kebersihan diri
Mandi :
Mandi sendiri/dibantu oleh ……………………………………….. ...............
Di ………………………………………………………………….................
Memakai sabun/tidak ……………………………………………… ..............
Dikeringkan dengan handuk/tidak …………………………………. .............
Gosok gigi : (dikerjakan sendiri/ditolong, menggunakan pasta gigi, waktu
menggosok gigi) ………………………………………………………..........
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H. Pengaturan suhu tubuh
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I. Rasa nyaman
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 J. Rasa aman
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K. Belajar (anak dan orangtua)

Pengetahuan tentang makanan, sebab-sebab penyakit, kesehatan lingkungan,
personal hygiene, tumbuh kembang anak, pendidikan seks, keluarga berencana
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L. Prestasi
Kepandaian anak sekarang, prestasi yang dimiliki
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M. Hubungan sosial anak

Hubungan inter keluarga (orang yang dirasa paling dekat, orang yang
dominan, orang yang disegani, hubungan, komunikasi anak dan orang tua
serta anggota keluarga lain)
……………………………………………………………………………......
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N. Melaksanakan ibadah (kebiasaan, bantuan yang diperlukan terutama saat anak
sakit)
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VI. PENGAWASAN KESEHATAN
Bila sehat diawasi di tidak/ya di puskemas, dokter, dll
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Bila sakit minta pertolongan kepada
……………………………………………………………………………..................
Kunjungan ke Posyandu
………………………………………………………………………………..............
Pengawasan anak dirumah
………………………………………………………..................................................
Imunisasi ( 1 – 5 tahun)

Imunisasi Umur Tgl diberikan Reaksi Tempat Imunisasi

BCG

DPT I, II, III

HB I, II, III
 CAMPAK

Tambahan / anjuran

VII. PENYAKIT YANG PERNAH DIDERITA

No Jenis Akut/Kronis Umur Lamanya Pertolongan
Penyakit /Menular/tidak saat
Sakit

VIII. KESEHATAN LINGKUNGAN

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IX. PERKEMBANGAN ANAK (0 – 6 tahun)
(Motorik kasar, motorik halus, bahasa, personal sosial)
………………………………………………………………………………..............
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X. PEMERIKSAAN FISIK
A. Kesan umum (kebersihan, pergerakan, penampilan/postur/bentuk tubuh, termasuk
status gizi)
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B. Warna kulit (pucat, normal, cyanosis, ikterus, kelainan)
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C. Suara waktu menangis :………………………………………………………… .
D. Tonus otot :…………………………………………………………………… ....
E. Turgor kulit :……………………………………………………. .........................
F. Udema : ada/tidak, di ……………………………. ...............................................
G. Kepala
Bentuk, keaadaan rambut dan kulit kepala, UUB, adanya kelainan
……………………………….……………………………………….............
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H. Mata :
Bentuk bola mata, pergerakannya, keadaan pupil, konjungtiva, keadaan kornea
mata, sclera, bulu mata serta ketajaman penglihatan
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I. Hidung :
Adanya secret, pergerakkan cuping hidung, adanya suara saat bernafas,
gangguan lain
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J. Telinga
Kebersihan, keadaan alat pendengaran, kelainan
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K. Mulut:
Kebersihan daerah sekitar mulut, keadaan selaput lendir, keadaan
tenggorokan, kelainan. Keadaan gigi (berlubang, karang gigi, kebersihan gigi,
gusi, kerusakan lain) keadaan lidah
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L. Leher:
Pembesaran kelenjar/pembuluh darah, kaku kuduk, pergerakkan leher
…………………….…………………………………………………….........
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M. Thoraks:
Bentuk dada, irama pernafasan, tarikan otot bantu pernafasan, adanya suara
nafas
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 …………………………………………………………………......................
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N. Jantung : (bunyi, pembesaran)
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O. Persarafan : (seflek fisiologis, reflek patologis)
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P. Abdomen :
Bentuk, pembesaran organ, keadaan pusat, teraba skibala, massa, nyeri pada
perabaan, distensia, hernia, peristaltic
……………………………………………………………………………......
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Q. Ekstremitas :
Kelainan bentuk, pergerakan, reflek lutut, adanya udem, keadaan unjung
ekstremitas, hal-hal lain
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R. Alat kelamin :
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S. Anus :
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T. Antropometri (ukuran pertumbuhan)

1. BB = kg
2. TB = cm
3. Lingkar kepala = cm
4. Lingkar dada = cm
5. Lingkar lengan = cm
U. Gejala kardinal :
1. Suhu =
2. Nadi =
3. Pernafasan =
4. Tekanan darah=
XI. PEMERIKSAAN PENUNJANG
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XII. HASIL OBSERVASI
1. Interaksi anak dengan orang tua
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2. Bentuk/arah komunikasi
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3. Ambivalensi/kontradiksi Prilaku
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4. Rasa aman anak
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XIII. ANALISA DATA

TGL/JAM DATA FOKUS INTERPRETASI/PENYEBAB MASALAH

XIV. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS

No Tanggal Diagnosa Keperawatan Tanggal TTD

muncul teratasi
XV. INTERVENSI/RENCANA KEPERAWATAN

No Tgl Diagnosa Tujuan & Intervensi Rasional Nama/TTD

Keperawatan Kriteria
Hasil
XVI. IMPLEMENTASI/TINDAKAN KEPERAWATAN

No Tanggal Nomor Jam Implementasi Evaluasi Nama/TTD

Diagnosa
 XVII. EVALUASI KEPERAWATAN

No Hari/Tgl Jam No. Dx Evaluasi TTD