ASUHAN KEPERAWATAN ANAK

DI RUANG DADAP SEREP RSUD PANDAN ARANG BOYOLALI

Tgl/Jam MRS : …………………………………………………………….

Tanggal/Jam Pengkajian : …………………………………………………………….
Metode Pengkajian : …………………………………………………………….
Diagnosa medis : …………………………………………………………….
No. Rekam Medis : …………………………………………………………….

I. Kasus Asuhan Keperawatan

A. Pengkajian
1. Identitas Klien
a. Nama : ……………………………………………......................

b. Tempat/Tgl Lahir : ……………………………………………......................

c. Umur : ……………………………………………......................

d. Alamat : ……………………………………………......................

e. Agama : ……………………………………………......................

f. Nama Ayah/Ibu : ……………………………………………......................

g. Pekerjaan Ayah : ………………………………………….........................

h. Pekerjaan Ibu : ……………………………………………......................

i. Pendidikan Ayah : ……………………………………………......................

j. Pendidikan Ibu : ……………………………………………......................

k. Suku Bangsa : ……………………………………………......................

2. Keluhan Utama

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3. Riwayat Penyakit Sekarang

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4. Riwayat Masa Lampau

a. Penyakit waktu kecil
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b. Pernah di rawat di rumah sakit
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c. Obat – obatan yang pernah digunakan sebelumnya
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 d. Pernah dilakukan tindakan seperti operasi atau yang lain – lain
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e. Alergi
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f. Kecelakaan
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g. Imunisasi
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5. Riwayat Genogram Keluarga
6. Riwayat Sosial
a. Yang mengasuh
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b. Hubungan dengan anggota keluarga
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c. Hubungan dengan teman sebaya
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d. Pembawaan secara umum
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 e. Lingkungan rumah
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7. Pemeriksaan Fisik
a. Keadaan Umum:

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b. Tanda vital :
Nadi : ............................................... Suhu : ................................................
RR : ............................................... SpO2 : ...............................................

c. Pengukuran Antropometri

Berat badan : ...........................................................................................................

Panjang badan : ...........................................................................................................
Lingkar kepala : ...........................................................................................................
Lingkar dada : ............................................................................................................
Lingkar lengan atas : ....................................................................................................

d. Riwayat Imunisasi
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e. Mata :
Bentuk : ……………………………………………………………….......................
Kebersihan :…………………………………………………………….....................
Palpebra : ………………………………………………………………....................
Konjungtiva : …………………………………………………………......................
Sclera : …………………………………………………………………...................
Pupil : ………………………………………………………………….....................
Reflek terhadap cahaya : ………………………………………………....................
f. Hidung
Sekret : ………………………………………………………………….....................
Polip : …………………………………………………………………......................
Napas cuping hidung : ………………………………………………….....................

g. Mulut
Keadaaan bibir : ………………………………………………………......................
Selaput mukosa : ……………………………………………………….....................
Warna lidah : ………………………………………………………….......................
Bau nafas : ……………………………………………………………......................
Dahak/muntahan : ….………………………………………………….....................

h. Telinga
Bentuk : ……………………………………………………………….......................
Kebersihan : ……………………………………………………………....................
Serumen : …………………………………………………………….......................

i. Tengkuk / leher
Bentuk : ………………………………………………………………......................
Pembesaran tyroid : ……………………………………………………....................
Kelenjar getah bening : ………………………………………………......................
JVP : …………………………………………………………………......................

j. Integumen

Warna kulit :................................................................................................................

Kelembaban : ...............................................................................................................
Lesi : ................................................................................................................
Kelainan : ................................................................................................................
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k. Paru – paru
Inspeksi : .................................................................................................................

Palpasi : .................................................................................................................

Perkusi : .................................................................................................................

Auskultasi : .................................................................................................................
l. Jantung

Inspeksi : .................................................................................................................

Palpasi : .................................................................................................................

Perkusi : .................................................................................................................

Auskultasi : .................................................................................................................

m. Abdomen

Inspeksi : .................................................................................................................

Auskultasi : .................................................................................................................

Palpasi : .................................................................................................................

Perkusi : .................................................................................................................

n. Genetalia

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m. Ekstrimitas
a. Atas
Kekuatan Otot : ........................................................................................ ..............

ROM : .....................................................................................................................

Pergerakan Sendi : ..................................................................................................

Perubahan Bentuk Tulang : ....................................................................................

Akral : .....................................................................................................................

Pitting Edema : .......................................................................................................

Terpasang infus : .....................................................................................................

 b. Bawah
Kekuatan Otot : .......................................................................................................

ROM : .....................................................................................................................

Varises : ...................................................................................................................

Perubahan Bentuk Tulang : .....................................................................................

Akral : .....................................................................................................................

Pitting Edema : .......................................................................................................

n. Pemeriksaan Neurologis

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8. Pemenuhan Kebutuhan Dasar

a. Oksigen
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b. Cairan
1. BAK

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2. BAB

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 Analisis Keseimbangan Cairan Selama Perawatan
Intake Output Analisis

a. Minuman : ............... cc a. Urine : ................ cc

Intake : ............... cc
b. Makanan : ................ cc b. Feses : ................ cc
Output : ............. cc
c. Infus : ................. cc c. IWL : ................. cc

Total : Total : Balance :

c. Nutrisi

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d. Tidur / Istirahat

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e. Pola Perceptual
1. Nyeri

P : ..............................................................................................................................
Q : ..............................................................................................................................
R : ..............................................................................................................................
S : ...............................................................................................................................
T : ...............................................................................................................................
9. Pemeriksaan Penujang

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10. Terapi/Pengobatan/Penatalaksanaan
Cairan IV : ..........................................................................................................................
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Obat Peroral : .....................................................................................................................
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Obat Parenteral : .................................................................................................................
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Obat Topikal : .....................................................................................................................
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Surakarta, ..............................................

Mahasiswa

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