BAB III

ASUHAN KEPERAWATAN PADA ANAK

I. PENGKAJIAN
A. Data Demografi
1. Klien/Pasien
b. Tanggal pengkajian : ...................................
c. Tanggal masuk : ...................................
d. Ruangan : ..................................
e. Identitas
 Nama : ...................................
 Tanggal lahir/umur: ................................
 Jenis kelamin : ...................................
 Agama : ...................................
 Suku : ...................................
 Diagnosa medis : ...................................
 Penanggung jawab: ...............................

2. Orang Tua/ Penanggung Jawab

a. Nama : ………………………...
b. Hubungan dengan klien : …………………………
c. Suku : ………………………...
d. Agama : …………………………
e. Alamat : …………………………
....................................
f. No. telepon : ………………….........

B. Riwayat Klien
1. Riwayat penyakit klien sebelumnya : ……………………
…………………………………………………….................
............................................................................................
2. Riwayat kehamilan (ANC, masalah kesehatan selama kehamilan, dll) :
.........................................................................................
.........................................................................................
 3. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit
persalinan, dll):
……………………………………………………............................................................
.......................................................................................................................................
......................................................................................................................................
4. Riwayat imunisasi (lengkapi)
Hepatitis B I BCG
Hepatitis B II Hepatitis B III
Polio I Polio II
Polio III Polio IV
DPT I DPT II
DPT III Campak
LAINNYA,sebutkan ……..........................................

5. Riwayat alergi : …………….................................

6. Riwayat pemakaian obat-obatan : ...…….......................

7. Riwayat tumbuh kembang (Sejak lahir hingga sekarang):

Motorik halus: .....................................................................
............................................................................................
Motorik kasar: ....................................................................
............................................................................................
Bahasa: ..............................................................................
............................................................................................
Personal sosial: ..................................................................
............................................................................................
Reflek primitif (Neonatus): .................................................
............................................................................................

C. Riwayat Kesehatan Keluarga

1. Riwayat penyakit dalam keluarga:
………………………………………………........…..................................................
....………………………………………………………………………………………....
...............................................................................................................................
 2. Genogram

Keterangan gambar :
: laki-laki : klien
: perempuan : meninggal
: tinggal dalam satu rumah

D. Riwayat Penyakit sekarang

1. Penampilan umum
a. Keadaan umum (kondisi klien secara umum):
…………………………………………………………...............................................
.................................................................................................................................
.................................................................................................................................
b. Pemeriksaaan Tanda-Tanda Vital
1) Pernapasan : ....................
2) Suhu : .....................
3) Nadi : .....................
4) Tekanan Darah: ...................
5) Saturasi oksigen: ..................

c. Penggunaan alat bantu napas (Oksigen, CPAP, dll)

................................................................................................................................
2. Nutrisi dan cairan:
a. Lingkar Lengan atas :..................cm
b. Panjang badan/tinggi badan: ................cm
c. Berat badan : .................kg
d. Lingkar kepala : ................ cm
e. Lingkar dada : ................... cm
f. Lingkar perut : ....................cm
 g. Status nutrisi (z-score atau WHO, CDC): ...........................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
h. Kebutuhan kalori : ........................................................
i. Jenis makanan : ...................................................................................
Makanan yang disukai : ...................................................................................
Alergi makanan : ..................................................................................
j. Kesulitan saat makan : ................................................................................
..............................................................................................................................
k. Kebiasaan khusus saat makan : .........................................................................
.............................................................................................................................
l. Keluhan (mual, muntah, kembung, anoreksia, dsb...):
.............................................................................................................................
.............................................................................................................................
a. Kebutuhan cairan 24 jam:............................................
b. Balance cairan (hitung jumlah dan jenis cairan masuk dan keluar):
.............................................................................................................................
..............................................................................................................................
..............................................................................................................................
c. Diuresis : ......................................................
d. Rute cairan masuk (oral, parenteral, enteral, dsb)
................................................................................................................................
................................................................................................................................
e. Jenis cairan (ASI/susu formula/infus/air putih, dsb):
................................................................................................................................
................................................................................................................................
f. Keluhan : ..............................................................................................................
................................................................................................................................

3. Istirahat tidur
a. Lama waktu tidur (24 jam) : ……… jam
b. Kualitas tidur : ..................................................................................................
c. Tidur siang (ya/tidak)
d. Kebiasaan sebelum tidur : ......................................................................................
4. Pengkajian nyeri (sesuai usia, lampirkan alat ukur):
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
.......................................................................................................................................
5. Pemeriksaan Fisik (Head to toe)
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
.......................................................................................................................................

6. Psikososial anak dan keluarga

a. Respon hospitalisasi (rewel, tenang).......................................................................
.................................................................................................................................
b. Kecemasan (anak dan orang tua) ..........................................................................
.................................................................................................................................
.................................................................................................................................
c. Koping klien/keluarga dalam menghadapi masalah
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
d. Pengetahuan orang tua tentang penyakit anak
.................................................................................................................................
.................................................................................................................................
e. Keterlibatan orang tua dalam perawatan anak .......................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
f. Konsep diri
.................................................................................................................................
.................................................................................................................................
g. Spiritual (kebiasaan ibadah, keyakinan, nilai, budaya)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
 h. Adakah terapi lain selain medis yang dilakukan .....................................................
.................................................................................................................................
7. Pemeriksaan penunjang (laboratorium, radiologi)
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................

8. Terapi:
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
9. ANALISA DATA
NO DATA PROBLEM ETIOLOGI
10. PROBLEM LIST
NO TGL/JAM DX KEP TTD TGL/JAM TTD
DITEMUKAN TERATASI
11. RENCANA KEPERAWATAN
NO TGL DX KEP INTERVENSI
/JAM TUJUAN TINDAKAN TTD
12. IMPLEMENTASI

NO No. DX KEP TGL IMPLEMENTASI RESPON TTD

/JAM
13. EVALUASI (perkembangan setiap hari dalam bentuk SOAP)

NO TGL/JAM DX KEP EVALUASI TTD

S:

O:

A:

P: