ASUHAN KEPERAWATAN PADA An…….

(USIA…tahun) DENGAN GANGGUAN

SISTEM …………………..: JENIS PENYAKIT……
DI RUANG ………….. RSUD KOTA BANDUNG

A. Pengkajian
1. Identitas
a. Identitas klien
Nama :
Umur :
Jenis kelamin :
Agama :
Pendidikam :
Suku bangsa :
Alamat :
No medrec :
Dx. medis :
Tgl masuk RS :
Tanggal pengakajian :
b. Penanggung jawab
Nama :
Umur :
Pekerjaan :
Hub. Dengan klien :
2. Alasan Masuk Rumah Sakit
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3. Keluhan Utama
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4. Riwayat Penyakit Sekarang

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5. Riwayat Kesehatan Dahulu
a. Riwayat Reproduksi (kehamilan dan kelahiran)
a) Pre natal
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b) Natal
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c) Post natal (24 jam pertama – 28 hari)
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b. Riwayat pemberian makan
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c. Penyakit pada masa kanak-kanak
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d. Riwayat alergi
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 e. Imunisasi
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6. Riwayat Kesehatan Keluarga
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7. Riwayat Tumbuh Kembang
a. Riwayat pertumbuhan
a) Berat badan
 Pada saat sehat :
 Pada saat sakit :
b) Lingkar kepala :
c) Lingkar dada :
d) Lingkar lengan atas :
e) Lingkar perut :
b. Riwayat perkembangan
a) Neonatal (0-28 hari)
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b) Infant (28 hari-1 tahun)
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c) Toodler (1-3 tahun)
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d) Pre school (3-6 tahun)
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 e) School (6-18 tahun)
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8. Riwayat Sosial Anak
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9. Pemeriksaan Fisik
a. Keadaan umum
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b. Tanda – tanda vital
Suhu :
Nadi :
Tekanan darah :
Respirasi :
c. Pemeriksaan head to toe
a) Kepala , kulit kepala, rambut
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b) Wajah , mata, hidung, mulut
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c) Telinga
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d) Leher
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e) Thorak / dada
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f) Abdomen
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 g) Genitalia
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h) Ekstremitas
Atas
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Bawah
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d. Data penunjang
a) Hasil laboratorium
Nama : Tanggal :
Jenis kelamin : No Medrek :
 b) Pemeriksaan lain/tambahan
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10. Spiritual Anak dan Keluarga
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11. Pola Aktivitas Sehari-hari
No Pola Aktivitas Pada saat sehat Pada saat sakit
1. Nutrisi
a. Makan
 Jenis
 Untuk bayi ASI/PASI,
makanan tambahan sejak
kapan diberikan
 Frekuensi
 Pantangan
 Kesulitan
 Sendiri/dibantu
b. Minum
 Jenis
 Frekuensi
 Pantangan
 Kesulitan
2 Eliminasi
a. BAK
 Frekuensi
 Warna
 Bau
 Kesulitan
b. BAB
 Frekuensi
 Warna
  Bau
 Kesulitan
3 Istirahat dan Tidur
a. Siang
 Frekuensi
 Kualitas tidur
 Tidur sendiri/ditemani
 Kesulitan tidur
 Pengantar tidur (ada/tidak)
b. Malam
 Frekuensi
 Kualitas tidur
 Tidur sendiri/ditemani
 Kesulitan tidur
 Pengantar tidur (ada/tidak)
4 Aktivitas berteman / bermain
a. Jenis permainan yang
dilakukan dan disukai
b. Teman-teman yang disukai
c. Waktu-waktu yang digunakan
ketika bermain
5 Personal Higyene
a. Mandi
 Frekuensi
 Pemakaian sabun
 Pemakaian air mandi
(hangat/dingin)
 Dibantu/sendiri
b. Gosok gigi
 Frekuensi
 Pemakaian pasta gigi
 Dibantu/sendiri
c. Shamppo
 Frekuensi
 Pemakaian shampoo
 Dibantu/sendiri
B. Analisa Data
No Data Etiologic Masalah
C. Diagnose Keperawatan
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D. Intervensi
Diagnose Intervensi
No
keperawatan Tujuan Intervensi Rasional
E. Implementasi
Tanggal / jam Implementasi Dx Paraf
F. Evaluasi
Tanggal / jam Catatan perkembangan Paraf