BAB III

ASUHAN KEPERAWATAN

I. PENGKAJIAN
A. Data Demografi
1. Klien/Pasien
a. Tanggal pengkajian : ......................................................................................
b. Tanggal masuk : ......................................................................................
c. Ruangan : ......................................................................................
d. Identitas
 Nama : ......................................................................................
 Tanggal lahir/umur : ......................................................................................
 Jenis kelamin : ......................................................................................
 Agama : ..........................................................................
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 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 sekarang :
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2. Riwayat penyakit klien sebelumnya :

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3. Riwayat kehamilan (ANC, masalah kesehatan selama kehamilan, dll) :

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4. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit
persalinan, dll) :
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5. Riwayat imunisasi
 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 :
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6. Riwayat pemakaian obat-obatan :
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7. Riwayat tumbuh kembang (kemampuan klien sekarang untuk anak sampai 72 bulan):
Motorik halus :
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Motorik kasar :
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Bahasa :
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Personal sosial :
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C. Riwayat Kesehatan Keluarga

1. Riwayat penyakit dalam keluarga:
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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) :
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b. Pemeriksaaan Tanda-Tanda Vital
1) Pernapasan : ....................
2) Suhu : .....................
3) Nadi : .....................
4) Tekanan Darah : ...................
5) Saturasi oksigen : ..................
c. Penggunaan alat bantu napas (Oksigen, dll)
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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) :
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h. Kebutuhan Kalori dan perhitungannya :
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i. Jenis makanan/diet saat ini di RS:
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Makanan yang disukai sebelum sakit dan saat ini:
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Alergi makanan
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j. Kesulitan saat makan
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k. Kebiasaan khusus saat makan :

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l. Keluhan (mual, muntah, kembung, anoreksia, dsb) :
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m. Kebutuhan cairan 24 jam :
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n. Balance cairan (hitung jumlah dan jenis cairan masuk dan keluar):
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o. Diuresis :
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p. Rute cairan masuk (oral, parenteral, enteral, dsb)
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q. Jenis cairan (ASI/susu formula/infus/air putih, dsb):
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r. Keluhan terkait cairan:
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3. Istirahat tidur
a. Lama waktu tidur (24 jam) : …………………………. jam
b. Kualitas tidur : …………..........................
c. Tidur siang (ya/tidak) : ……………………………
d. Kebiasaan sebelum tidur
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4. Pengkajian nyeri (sesuai usia, lampirkan alat ukur):
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5. Pemeriksaan Fisik (Head to toe)

a. Keadaan umum : …………………………………………………………
b. Kesadaran : …………………………………………………………
c. Vital sign :
 TD : …………………………… mmHg
 HR :…………………………….. x/menit
 RR :……………………………...x/menit
 Suhu : ………………………………oC
d. Kepala
Inspeksi :
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Palpasi :
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e. Mata
Inspeksi :
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Palpasi :
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f. Hidung
Inspeksi :
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Palpasi :
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g. Mulut
Inspeksi :
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Palpasi :
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h. Telinga
Inspeksi :
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Palpasi :
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i. Leher
Inspeksi :
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Palpasi :
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j. Paru-paru
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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k. Jantung
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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l. Abdomen
Inspeksi :
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Auskultasi:
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Perkusi :
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Palpasi :
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m. Genitalia
Inspeksi :
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n. Ekstremitas atas
Kanan Kiri

Baal Nyeri Edema Lemas Baal Nyeri Edema Lemas

Kekuatan otot : Kiri ( ), Kanan ( )

o. Ekstremitas bawah
Kanan Kiri

Baal Nyeri Edema Lemas Baal Nyeri Edema Lemas

Kekuatan otot : Kiri ( ), Kanan ( )

6. Psikososial anak dan keluarga

a. Respon hospitalisasi (rewel, tenang) : .................................................................
b. Kecemasan (anak dan orang tua) : ....................................................................
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c. Koping klien/keluarga dalam menghadapi masalah :
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d. Pengetahuan orang tua tentang penyakit anak :

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e. Keterlibatan orang tua dalam perawatan anak :
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f. Konsep diri :
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g. Spiritual (kebiasaan ibadah, keyakinan, nilai, budaya) :
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h. Adakah terapi lain selain medis yang dilakukan :
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PEMERIKSAAN PENUNJANG
PEMERIKSAAN PENUNJANG
PEMERIKSAAN PENUNJANG
PEMERIKSAAN PENUNJAN
 8. Terapi :
Jenis Terapi Dosis Rute Indikasi Kontra Indikasi Efek Samping
ANALISA DATA
NO DATA PROBLEM ETIOLOGI
PROBLEM LIST
TGL/JAM TGL/JAM
NO DX KEP TTD TTD
DITEMUKAN TERATASI
RENCANA KEPERAWATAN
TGL
INTERVENSI
DX KEP
NO /JAM
TINDAKAN TTD
TUJUAN
IMPLEMENTASI
TGL
NO DX KEP IMPLEMENTASI RESPON TTD
/JAM
EVALUASI
NO TGL/JAM DX KEP EVALUASI TTD