ASUHAN KEPERAWATAN

ANAK
Nama Mahasiswa : _______________________________________
Tempat Praktik : _______________________________________
Tanggal : _______________________________________

A. PENGKAJIAN
1. Identitas Klien
Nama : _________________________________
Tempat tgl lahir/usia : _________________________________
JenisKelamin : _________________________________
Agama : _________________________________
Pendidikan : _________________________________
Alamat : _________________________________
Tgl masuk : _________________________________
Tgl pengkajian : _________________________________
Diagnosa medik :_________________________________
Rencana terapi :_________________________________
2. Identitas Orang Tua
a. Ayah
Nama : ___________________________________
Usia : ___________________________________
Pendidikan : ___________________________________
Pekerjaan/sumber penghasilan : ___________________________________
Agama : ___________________________________
Alamat : ___________________________________
b. Ibu
Nama : ___________________________________
Usia : ___________________________________
Pendidikan : ___________________________________
Pekerjaan/sumber penghasilan : ___________________________________
Agama : ___________________________________
Alamat : ___________________________________

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B. RIWAYATKESEHATAN
1. Riwayat Penyakit Sekarang
a. Keluhan utama
_________________________________________________________________
_________________________________________________________________
b. Riwayat perjalanan penyakit
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

2. RiwayatKesehatan Lalu (khusus untuk anak usia 0 – 5 tahun)

a. Prenatal Care
1) Ibu memeriksakan kehamilannya setiap minggu di
______________________________________________________________
______________________________________________________________
Keluhan selama hamil yang dirasakan ioleh ibu, tapi oleh dokter dianjurkan
untuk
______________________________________________________________
______________________________________________________________
2) Riwayat terkena radiasi
______________________________________________________________
______________________________________________________________
3) Riwayat berat badan selama hamil
______________________________________________________________
______________________________________________________________
4) Riwayat Imunisasi TT
______________________________________________________________
______________________________________________________________
5) Golongan darah ibu _________ Golongan darah ayah __________

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 b. Natal
1) Tempat melahirkan
______________________________________________________________
______________________________________________________________
______________________________________________________________
2) Jenis persalinan
______________________________________________________________
______________________________________________________________
3) Penolong persalinan
______________________________________________________________
______________________________________________________________
4) Komplikasi yang dialami oleh ibu pada saat melahirkan dan setelah
melahirkan
______________________________________________________________
______________________________________________________________
______________________________________________________________
c. Post Natal
1) Kondisi bayi __________________________
2) APGAR _________________________________
3) Anak pada saat lahir mengalami
a) Klien pernah mengalami penyakit
___________________________________________________________
Pada umur _________________ diberikan obet oleh
___________________________________________________________
b) Riwayat mengkonsumsi obat-obatan berbahaya tanpa anjuran dokter dan
menggunakan zat/subtansi kimia yang berbahaya
___________________________________________________________
___________________________________________________________
3. Riwayat Penyakit Keluarga
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

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 4. Genogram

Ket. :

C. RIWAYAT IMUNISASI (IMUNISASI LENGKAP)

WAKTU REAKSI SETELAH
NO JENIS IMUNISASI FREK. FREK.
PEMBERIAN PEMBERIAN

1 BCG

2 DPT (I, II, III)

3 Polio (I, II, III, IV)

4 Campak

5 Hepatitis

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D. RIWAYAT TUMBUH KEMBANG
1. Pertumbuhan Fisik
a) Berat badan : _____________ kg
b) Tinggi badan : _____________ cm
c) Waktu tumbuh gigi _________________ gigi tangal ________________ jumlah
gigi _____ buah
2. Perkembangan Tiap Tahap
a) Usia anak saat
1) Berguling : ___________________ bulan
2) Duduk : ___________________ bulan
3) Merangkak : ___________________ bulan
4) Berdiri : ___________________ bulan
5) Berjalan : ___________________ bulan
6) Senyum kepada orang lain pertama kali : __________________ tahun
7) Bicara pertama kali : __________________ tahun
8) Berpakaian tanpa bantuan : _____________________ tahun

E. RIWAYAT NUTRISI
1. Pemberian ASI
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2. Pemberian Susu Formula
a) Alasan pemberian :
_________________________________________________________________
b) Jumlah pemberian :
_________________________________________________________________
c) Cara pemberian :
_________________________________________________________________

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F. RIWAYAT PSIKOSOSIAL
1. Anak tinggal bersama ___________________________

G. RIWAYAT SPIRITUAL
1. Support sistem dalam keluarga
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2. Kegiatan keagamaan
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

H. REAKSI HOSPITALISASI
1. Pengalaman keluarga tentang sakit dan rawat inap
a) Ibu membawa anaknya ke RS karena
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
b) Perasaan orang tua saat ini
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
c) Orang tua selalu berkunjung ke RS
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

d) Yang akan tinggal dengan anak

_________________________________________________________________
_________________________________________________________________

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I. AKTIFITAS SEHARI-HARI
1. Nutrisi
KONDISI SEBELUM SAKIT SAKIT

Selera makan

2. Cairan
KONDISI SEBELUM SAKIT SAKIT

Jenis minum

Frekuensi minum

Kebutuhan cairan

Cara pemenuhan

3. Eliminasi (BAB & BAK)

KONDISI SEBELUM SAKIT SAKIT

Tempat pembuangan

Konsistensi

4. Istirahat
KONDISI SEBELUM SAKIT SAKIT

Jam tidur

Siang

Malam

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 5. Personal Higine
KONDISI SEBELUM SAKIT SAKIT
MANDI

Cara

Frekuensi

Alat mandi

J. PEMERIKSAAN FISIK
1. KeadaanUmum
____________________________________________________________________
____________________________________________________________________
2. Kesadaran
____________________________________________________________________
3. Tanda-Tanda Vital
Tekanan darah : __________ mmHg Suhu : __________ 0C
Nadi : __________ x/menit Respirasi rate :__________
x/menit
4. Berat badan : __________ kg
Tinggi badan : __________ cm
5. Kepala
1) Rambut
Inspeksi :
a. Warna rambut :
___________________________________________________________
b. Penyebaran :
___________________________________________________________
c. Mudah rontok :
___________________________________________________________

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 d. Kebersihan rambut :
___________________________________________________________
Palpasi :
a. Benjolan : ada / tidak
b. Nyeri tekan : ada / tidak
c. Tekstur rambut : kasar / halus
2) Muka
Inspeksi :
a. Simetris / tidak :
___________________________________________________________
b. Bentuk wajah :
___________________________________________________________
c. Gerakan abnormal :
___________________________________________________________
d. Ekspresi wajah :
___________________________________________________________
Palpasi
a. Nyeri tekan / tidak :
___________________________________________________________
b. Data lain :
___________________________________________________________
3) Mata
Inspeksi :
a. Pelpebra : edema / tidak
radang / tidak
b. Sclera : icterus / tidak
c. Conjungtiva : radang / tidak
anemis / tidak
d. Pupil : isokor / anisokor
myosis / midriasis
refleks pupil terhadap cahaya
___________________________________
e. Posisi mata : simetris / tidak

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 f. Gerakan bola mata :
___________________________________________________________
g. Nutup kelopak mata :
___________________________________________________________
h. Keadaan bulu mata : -
___________________________________________________________
i. Keadaan visus :
___________________________________________________________
j. Penglihatan : kabur / tidak
diplopia / tidak

Palpasi :
a. Tekanan bola mata :
___________________________________________________________
b. Data lain :
___________________________________________________________
4) Hidungdan sinus
Inspeksi :
a. Posisi hidung :
___________________________________________________________
b. Bentuk hidung :
___________________________________________________________
c. Keadaan septum :
___________________________________________________________
d. Secret / cairan :
___________________________________________________________
e. Data lain :
___________________________________________________________

5) Telinga
Inspeksi :
a. Posisi telinga : -
___________________________________________________________

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 b. Ukuran / bentuk :
___________________________________________________________
c. Aurikel :
___________________________________________________________
d. Lubang telinga : bersih / serumen / nanah
e. Pemakaian alat bantu :
___________________________________________________________
Palpasi :
a. Nyeri tekan / tidak :
___________________________________________________________
b. Pemeriksaan vestibuler:
___________________________________________________________
c. Data lain :
___________________________________________________________
6) Mulut
Inspeksi :
a. Gusi : merah / radang / tidak
b. Lidah : kotor / tidak
c. Bibir : cianosis / pucat / tidak
basah / kering / pecah
mulut berbau / tidak
kemampuan bicara
___________________________________________
d. Data lain :
___________________________________________________________
6. Leher
Inspeksi :
Kelenjar thyroid : membesar / tidak
Palpasi :
a. Kelenjar thyroid : teraba / tidak
b. Kaku kuduk : ada / tidak
c. Kelenjar limfe : membesar atau tidak

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 d. Data lain :
___________________________________________________________
7. Thorax dan pernafasan
Inspeksi :
a. Bentuk dada :
___________________________________________________________
b. Irama nafas :
___________________________________________________________
c. Tipe pernafasan :
___________________________________________________________
d. Data lain :
___________________________________________________________
Palpasi :
a. Vokal fremitus :
___________________________________________________________
b. Massa / nyeri :
___________________________________________________________
Auskultasi :
a. Suara nafas : vesikuler / bronchial / bronchovesikuler
b. Suara tambahan : ronchi / wheezing / rales
Perkusi :
a. Redup / pekak / hypersonor / tympani
b. Data lain :
___________________________________________________________
8. Jantung
Palpasi :
a. Ictus cordis :
___________________________________________________________
Perkusi :
a. Pembesaran jantung :
___________________________________________________________

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 Auskultasi :
a. BJ I :
___________________________________________________________
b. BJ II :
___________________________________________________________
c. BJ III :
___________________________________________________________
d. Bunyi jantung tambahan :
___________________________________________________________
e. Data lain :
___________________________________________________________
9. Abdomen
Inspeksi :
a. Membuncit :
___________________________________________________________
b. Ada luka / tidak :
___________________________________________________________
Palpasi :
a. Hepar :
___________________________________________________________
b. Lien :
___________________________________________________________
c. Nyeri tekan :
___________________________________________________________
Auskultasi :
a. Peristaltik :
___________________________________________________________
Perkusi :
a. Tympani :
___________________________________________________________
b. Data lain :
___________________________________________________________

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10. Genetalia
Inspeksi :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Palpasi :
____________________________________________________________________
____________________________________________________________________
11. Ekstremitas
Ekstermitas atas
a. Motorik
1) Pergerakan kanan / kiri :
_______________________________________________________________
2) Pergerakan abnormal :
_______________________________________________________________
3) Kekuatan otot kanan / kiri :
_______________________________________________________________
b. Sensori
1) Nyeri :
______________________________________________________________
2) Ransang suhu :
______________________________________________________________
3) Rasa raba :
______________________________________________________________
Ekstermitas bawah
a. Sensori
1) Nyeri :
______________________________________________________________
2) Ransang suhu :
______________________________________________________________
3) Rasa raba :
______________________________________________________________

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K. TES DIAGNOSTIK
1. Laboratorium
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
2. Foto Rotgen, CT Scan, MRI, USG, EEG, ECG
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
L. TERAPI SAAT INI (DI TULIS SAAT INI)
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
4.
M. MASALAH KEPERAWATAN
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

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N. ANALISA DATA
Identitas Klien : ___________________ Tanggal :_____________
No. Reg : ___________________ Diagnosa Mds : _____________
MASALAH
NO DATA ETIOLOGI
KEPERAWATAN

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O. DIAGNOSA KEPERAWATAN
1. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

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