ASUHAN KEPERAWATAN PADA An. ....... Dengan ......................................

Di Ruang ................................ RS .........................................................

A. PENGKAJIAN
I. IDENTITAS
Nama :
Jenis Kelamin :
Tanggal Lahir :
Umur :
Nama ayah :
Nama ibu :
Pekerjaan ayah :
Pekerjaan ibu :
Alamat :
Suku :
Agama :
Pendidikan :

II. KELUHAN UTAMA

III. RIWAYAT K ES EH ATAN S EK ARAN G

IV. RIWAYAT KESEHATAN MASA LAMPAU

1. Riwayat kehamilan dan kelahiran
a. Prenatal :

b. Natal :
 c. Postnatal :

2. Penyakit waktu kecil

3. Riwayat Hospitalisasi

4. Obat- obat yang pernah digunakan

5. Tindakan (operasi) yang pernah dilakukan

6. Alergi

7. Kecelakaan

8. Imunisasi
No Imunisasi Waktu Frekuensi Efek
Pemberian Pemberian Pemberian
Imunisasi Dasar
 Imunisasi Lanjutan

V. RIWAYAT KESEHATAN KESEHATAN KELUARGA

1. Pohon Keluarga (Genogram)

2. Penyakit Keluarga

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3. Kebiasaan Keluarga

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4. Pola Asuh Keluarga

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VII. RIWAYAT TUMBUH KEMBANG

1. Riwayat Pertumbuhan (jelaskan pertumbuhan bayi/ anak sejak usia 1 bulan
hingga dilakukan pengkajian)

2. Riwayat Perkembangan (jelaskan perkembangan bayi/ anak sejak usia 1 bulan

hingga dilakukan pengkajian)

VIII. PEMERIKSAAN FISIK

1. Keadaan Umum: .........................................................................................................................
Kesadaran : .........................................................................................................................
GCS : .........................................................................................................................
Tanda-tanda vital:
TD : ................../................. mmHg Nadi : ............... x/menit
Suhu: ..............°C Respirasi: ................ x/menit
2. Pemeriksaan Kulit dan Kuku
Inspeksi
Warna Kulit : ...............................................................................................................................
Keterangan : ...............................................................................................................................
Palpasi
Kondisi Kulit : ...............................................................................................................................
Turgor Kulit : ...............................................................................................................................
CRT : ...............................................................................................................................
Keterangan : ...............................................................................................................................
3. Pemeriksaan Kepala
Inspeksi
Bentuk Kepala:...............................................................................................................................
Rambut : ...............................................................................................................................
Massa : ...............................................................................................................................
Keterangan : ...............................................................................................................................
Palpasi
Kepala: .............................................................................................................................................
Keterangan: ...................................................................................................................................
4. Pemeriksaan Mata
Inspeksi
Alis : ..................................................................................................................................
Mata : ..................................................................................................................................
Bola Mata : ..................................................................................................................................
Sklera : ..................................................................................................................................
Pupil : ..................................................................................................................................
Konjungtiva: ..................................................................................................................................
Keterangan : ..................................................................................................................................
Palpasi
Mata : ..................................................................................................................................
Keterangan : ..................................................................................................................................
5. Pemeriksaan Hidung
Inspeksi
Lubang hidung : .........................................................................................................................
Hidung : .........................................................................................................................
Keterangan : .........................................................................................................................
Palpasi
Sinus Hidung : .........................................................................................................................
Keterangan : .........................................................................................................................
6. Pemeriksaan Telinga
Inspeksi
Daun Telinga : .........................................................................................................................
Kondisi lubang Telinga: ..............................................................................................................
Keterangan : .........................................................................................................................
Palpasi
Telinga : .........................................................................................................................
Keterangan : .........................................................................................................................
7. Pemeriksaan Mulut
Inspeksi
Bibir : .........................................................................................................................
Gigi : .........................................................................................................................
Gusi : .........................................................................................................................
 Lidah : .........................................................................................................................
Uvula : .........................................................................................................................
Tonsil : .........................................................................................................................
Keterangan : .........................................................................................................................
Palpasi
Keterangan : .........................................................................................................................
8. Pemeriksaan Leher
Inspeksi
Kondisi Kulit : .........................................................................................................................
Keterangan : .........................................................................................................................
Palpasi
Kelenjar Tiroid : .........................................................................................................................
Vena jugularis : .........................................................................................................................
Trakea : .........................................................................................................................
Kelenjar Limfe : .........................................................................................................................
Keterangan : .........................................................................................................................
9. Pemeriksaan Paru
Inspeksi
Dada : .........................................................................................................................
Kondisi kulit : .........................................................................................................................
Keterangan : .........................................................................................................................
Palpasi
Pada Dada : .........................................................................................................................
Perkusi : .........................................................................................................................
Auskultasi : .........................................................................................................................

Suara Nafas :

10. Pemeriksaan Jantung

Inspeksi
Ictus Cordis : .........................................................................................................................
Kondisi kulit : .........................................................................................................................
Keterangan : .........................................................................................................................
Palpasi
Ictus Cordis : .........................................................................................................................
Perkusi : .........................................................................................................................
Auskultasi : .........................................................................................................................
BJ I : .........................................................................................................................
BJ II : .........................................................................................................................
BJ III : .........................................................................................................................
BJ tambahan : .........................................................................................................................
Keterangan : .........................................................................................................................

11. Pemeriksaan Abdomen

Inspeksi : .........................................................................................................................
Auskultasi : .........................................................................................................................
Palpasi : .........................................................................................................................
Perkusi : .........................................................................................................................
Keterangan : .........................................................................................................................
12. Pemeriksaan Muskuloskeletal
 Inspeksi : .........................................................................................................................
Palpasi : .........................................................................................................................

Kekuatan Otot

Keterangan : .........................................................................................................................
13. Pemeriksaan Genetalia
Inspeksi : .........................................................................................................................
Palpasi : .........................................................................................................................
Keterangan : .........................................................................................................................

VIII. KEBUTUHAN DASAR

a. Pola Nutrisi dan Metabolik
Di Rumah
Makan berapa kali dalam sehari: ..........................................x/hari
Jumlah cairan masuk dalam sehari:....................................... cc/hari
Jenis makanan : ..........................................................................................
Jenis minuman : ..........................................................................................
Makanan kesukaan : ..........................................................................................
Masalah yang mempengaruhi masukan makanan:.........................................................
Diet khusus, makanan pantang:
Keterangan : ..........................................................................................
..............................................................................................................................................................
Di RS
Makan berapa kali dalam sehari: ..........................................x/hari
Jumlah cairan masuk dalam sehari:....................................... cc/hari
Jenis makanan : ..........................................................................................
Jenis minuman : ..........................................................................................
Makanan kesukaan : ..........................................................................................
Masalah yang mempengaruhi masukan makanan:.........................................................
Diet khusus, makanan pantang:
Status Gizi : BB=.......kg, TB=.......cm
Interpretasi status gizi : ............................................
Keterangan lain : ..........................................................................................
..............................................................................................................................................................
b. Pola Eliminasi
Di Rumah
No Hal BAB BAK
1. Frekuensi

2. Konsistensi

3. Jumlah

4. Bau

5. Warna
 Di RS
No Hal BAB BAK
1. Frekuensi

2. Konsistensi

3. Jumlah

4. Bau

5. Warna

c. Pola Kebersihan Diri

Di Rumah
Mandi : .......................................................................................................................
Gosok Gigi : .......................................................................................................................
Keramas : .......................................................................................................................
Gunting Kuku : .......................................................................................................................
Keterangan : .......................................................................................................................
..............................................................................................................................................................
Di RS
Mandi : .......................................................................................................................
Gosok Gigi : .......................................................................................................................
Keramas : .......................................................................................................................
Gunting Kuku : .......................................................................................................................
Keterangan : .......................................................................................................................
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d. Pola Aktivitas dan Latihan
Di Rumah:
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Di RS
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e. Pola Istirahat/Tidur
Di Rumah
Tidur Siang : berapa jam................; jam berapa biasa tidur............................
Tidur Malam : berapa jam................; jam berapa biasa tidur............................
Masalah Tidur : .........................................................................................................................
Keterangan : .........................................................................................................................

Di RS
Tidur Siang : berapa jam................; jam berapa biasa tidur............................
Tidur Malam : berapa jam................; jam berapa biasa tidur............................
 Masalah Tidur : .........................................................................................................................
Keterangan :........................................................................................................................

f. Persepsi Kesehatan/ Manajemen Kesehatan

g. Kognitif dan Perseptual

h. Konsep Diri

i. Hubungan-Peran

j. Seksualitas

k. Koping-Stress-Adaptasi
l. Nilai-Keyakinan

IX. PEMERIKSAAN PERTUMBUHAN DAN PERKEMBANGAN

1. Pertumbuhan
Indikator Hasil
Interpretasi
Antropometri Pengukuran
Berat Badan WAZ
Tinggi/Panjang Badan
LILA HAZ
LK
LD WHZ
LP

2. Perkembangan (lampirkan lembar hasil pemeriksaan DDST II untuk bayi/

anak usia 0-72 bulan)

Indikator
Hasil Pemeriksaan
Perkembangan
1. Personal
Sosial

2. Motorik Kasar

3. Motorik Halus

4. Bahasa

Kesimpulan
X. PEMERIKSAAN PENUNJANG (LABORATOTIUM, RADIOLOGI,DLL)
Pemeriksaan Hasil Nilai Normal Interpretasi
XI. TERAPI MEDIS

Nama & Dosis Rute Pemberian Fungsi Obat

Obat
B. ANALISA DATA
Nama/ Umur :
No Reg :

NO TGL DATA FOKUS MASALAH ETIOLOGI

KEPERAWATAN
PRIORITAS DIAGNOSA KEPERAWATAN
1.___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________

C. RENCANA KEPERAWATAN
TUJUAN DAN KRITERIA
NO DX INTERVENSI RASIONAL
HASIL
D. IMPLEMENTASI KEPERAWATAN

TANGGAL WAKTU IMPLEMENTASI TTD

E. EVALUASI KEPERAWATAN

NO TANGGAL EVALUASI TTD

DIAGNOSA