LAPORAN PENDAHULUAN DAN ASUHAN

KEPERAWATAN PADA ANAK

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Disusun Oleh :
NAMA : ..............................................
NIM : ..............................................

KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN KEMENKES MALANG
JURUSAN KEPERAWATAN
PROGRAM STUDI SARJANA TERAPAN
KEPERAWATAN LAWANG
TAHUN
FORMAT 2018
PENGKAJIAN
 A. PENGKAJIAN

A1. PENGUMPULAN DATA

I. BIODATA

IDENTITAS ANAK IDENTITAS BAPAK

Nama :..................................... Nama :.....................................
No. Register :..................................... Umur :.....................................
Umur (bln, hr) :..................................... Jenis kelamin :.....................................
Jenis kelamin :..................................... Alamat :.....................................
Alamat :..................................... Pendidikan :.....................................
Suku bangsa :..................................... Pekerjaan :.....................................
Tanggal lahir/Umur :..................................... Suku bangsa :.....................................
Tgl MRS :..................................... No. Tlp/HP
Tanggal pengkajian :..................................... :.....................................
Diagnosa medis :..................................... IDENTITAS IBU :.....................................
Urutan anak :.....................................
Nama :.....................................
Umur :.....................................
Jenis kelamin :.....................................
Alamat :.....................................
Pendidikan :.....................................
Pekerjaan :.....................................
Suku bangsa :.....................................
No. Tlp/HP :.....................................

II. KELUHAN UTAMA/ALASAN KUNJUNGAN

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III. RIWAYAT KESEHATAN

A. RIWAYAT PENYAKIT SEKARANG
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B. RIWAYAT KESEHATAN YANG LALU

1) Penyakit-penyakit waktu kecil _______________________________________________
2) Pernah dirawat di rumah sakit ______________________________________________
3) Obat-obatan ____________________________________________________________
 4) Tindakan (misalnya : operasi) _______________________________________________
5) Allergi _________________________________________________________________
6) Kecelakaan ____________________________________________________________
7) Imunisasi ______________________________________________________________

C. RIWAYAT TUMBUH KEMBANG

a. Prenatal ____________________________________________________________
____________________________________________________________________
b. Intranatal ___________________________________________________________
____________________________________________________________________
c. Post natal ___________________________________________________________
____________________________________________________________________
IV. Riwayat Keluarga
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
V. Riwayat Sosial
a. Yang mengasuh ________________________________________________________
b. Hubungan dengan anggota keluarga ________________________________________
c. Hubungan dengan teman sebaya ___________________________________________
d. Pembawaan secara umum ________________________________________________
e. Lingkungan rumah ______________________________________________________

VI. PEMERIKSAAN FISIK (HEAD TO TOE)

A. Keadaan Umum
Postur: .........................................................................................................................
Kesadaran: .................................................................................................................
B. Kepala dan rambut
Kebersihan : ...............................................................................................................
Bentuk kepala : ..........................................................................................................
Keadaan rambut :........................................................................................................
Keadaan kulit kepala : caput succedanum, cefalohematom: ....................................
Fontanela anterior : lunak/menonjol/tegas/cekung/datar: ........................................
Sutura sagitalis : tepat/terpisah/menjauh: .................................................................
Distribusi rambut : merata/tidak merata: ....................................................................
C. Mata
Kebersihan : ..................................................................................................................
 Pandangan : .................................................................................................................
Sclera : ..........................................................................................................................
Conjungtiva : .................................................................................................................
Pupil : .............................................................................................................................
Gerakan bola mata : .....................................................................................................
Sekret: ............................................................................................................................
D. Hidung
Pernafasan Cuping hidung : ..........................................................................................
Struktur :.........................................................................................................................
Kelainan lain : polip/perdarahan/peradangan: ...............................................................
Sekresi: ........................................................................................................................
E. Telinga
Kebersihan : .......................................................................................................................
Sekresi : .............................................................................................................................
Struktur : .............................................................................................................................
Fistula aurikel: ....................................................................................................................
Membran timpani: ..............................................................................................................
F. Mulut dan Tengorokan
Jamur (stomatitis, moniliasis): ...........................................................................................
Kelaianan bibir dan rongga mulut (gnato/labio/palato skizis): ............................................
Problem menelan : .............................................................................................................
G. Leher
Vena jugularis : ...................................................................................................................
Arteri karotis : .....................................................................................................................
Pembesaran tiroid dan limfe : ............................................................................................
Torticoliis: ..........................................................................................................................
H. Dada/Thorak (jantung dan Paru)
Bentuk dada: ......................................................................................................................
Pergerakan kedua dinding dada: ........................................................................................
Tarikan dinding dada ke atas/bawah: ..................................................................................
Suara pernafasan: ...............................................................................................................
Frekwensi nafas: .................................................................................................................
Abnormalitas suara nafas: ..................................................................................................
Suara jantung: ....................................................................................................................
I. Ekstremitas atas
Tonus otot: ..........................................................................................................................
CRT: ..................................................................................................................................
 Trauma, deformitas: ..........................................................................................................
Kelainan struktur: ................................................................................................................
J. Perut
Bentuk perut: ......................................................................................................................
Bising usus: .........................................................................................................................
Ascites: ..............................................................................................................................
Massa: ...............................................................................................................................
Turgor kulit: .......................................................................................................................
Vena: ..............................................................................................................................
Hepar: ..............................................................................................................................
Lien: .......................................................................................................................
Distensi: ............................................................................................................................
K. Punggung
Spina bifida: ........................................................................................................................
Deformitas: ........................................................................................................................
Kelainan struktur: ................................................................................................................
L. Kelamin dan anus
Keadaan kelamin luar (kebersihan, lesi, kelainan) : ..........................................................
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Anus : ...............................................................................................................................
Kelainan: ........................................................................................................................
M. Ekstremitas bawah
Tonus otot: .........................................................................................................................
Trauma, deformitas: ..........................................................................................................
Kelainan struktur: ..............................................................................................................
N. Integumen
Warna kulit: ......................................................................................................................
Kelembaban: .....................................................................................................................
Lesi: ..................................................................................................................................
Warna kuku : ....................................................................................................................
Kelainan: ..........................................................................................................................

VII. PENGUKURAN ANTROPOMETRI

Berat badan: ..........................................................................................................................
Panjang/Tinggi badan: .............................................................................................................
Lingkar kepala: ......................................................................................................................
Lingkar dada: ..........................................................................................................................
 Lingkar lengan Atas: ............................................................................................................
Kesimpulan Status gizi: Baik, kurus, Sangat kurus, Gemuk, Sangat gemuk (lingkari salah
satu)

VIII. RIWAYAT IMUNISASI

Sebutkan imunisasi yang sudah diberikan beserta umur saat diimunisasi
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IX. PEMENUHAN KEBUTUHAN DASAR

A. OKSIGEN
Kebutuhan oksigen: ..........................................................................................................
Dosis oksigen: ...................................................................................................................
Cara pemberian: ..........................................................................................................
B. CAIRAN:
Kebutuhan cairan dalam 24 jam: .....................................................................................
Jenis cairan yang diberikan: ...........................................................................................
Cara/rute pemberian: .......................................................................................................
Balance cairan dalam 24 jam:
Intake: ..............................................................................................................................
Output : ............................................................................................................................
IWL: ..............................................................................................................................
Kesimpulan: ..................................................................................................................
C. Nutrisi:
Kebutuhan kalori: ............................................................................................................
Bentuk/jenis nutrisi yang diberikan: ....................................................................................
Cara pemberian: .............................................................................................................
Frekwensi pemberian: ..................................................................................................
Alergi/Pantangan: .............................................................................................................
Nafsu makan: .............................................................................................................
D. ELIMINASI URINE
Volume urine: ..................................................................................................................
Warna: ............................................................................................................................
Frekwensi: .........................................................................................................................
Cara BAK (spontan/kateter): ............................................................................................
Kelaianan pemenuhan BAK: ............................................................................................
 E. ELIMINASI ALVI
Volume feses: ...................................................................................................................
Warna feses: ....................................................................................................................
Konsistensi: ....................................................................................................................
Frekwensi: .........................................................................................................................
Darah, lendir dalam feses: ................................................................................................
F. TIDUR
Jumlah jam tidur dalam 24 jam: .....................................................................................
Kualitas tidur (sering terbangun, rewel, tidak bisa tidur): ...............................................
G. PSIKOSOSIAL
Hubungan orangtua dengan anak: ......................................................................
Yang mengasuh: .........................................................................................................

X. TANDA-TANDA VITAL
a. Tekanan Darah : ............................................................................................................
b. Denyut Nadi : ............................................................................................................
c. Pernafasan : ............................................................................................................
d. Suhu Tubuh : ............................................................................................................

XI. PEMERIKSAAN TINGKAT PERKEMBANGAN (KPSP/Denver)

Interpretasi perkembangan :
KPSP
Sesuai
Meragukan
Penyimpangan
(Lampirkan KPSP)

Denver
Normal
Suspect
Untestable
(Lampirkan formulir Denver)
XII. DATA PENUNJANG
A. Radiologi
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

B. Laboratorium
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan
C. Pemeriksaan lainnya
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

Mengetahui, ...............................,.......................................
Pembimbing klinik
Mahasiswa

(.......................................................) (............................................................)
NIM.
A2. ANALISIS DATA

HARI/TGL : ...............................................................................................

NO KEMUNGKINAN
DATA MASALAH
PENYEBAB
B. DIAGNOSA KEPERAWATAN

NAMA & TANDA

NO TANGGAL DIAGNOSA KEPERAWATAN
TANGAN
C. RENCANA TINDAKAN KEPERAWATAN

DIAGNOSA TUJUAN DAN KRITERIA NAMA & TANDA

NO INTERVENSI RASIONAL
KEPERAWATAN HASIL TANGAN
 DIAGNOSA TUJUAN DAN KRITERIA NAMA & TANDA
NO INTERVENSI RASIONAL
KEPERAWATAN HASIL TANGAN PERAWAT
D. IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN

NAMA & TANDA

NO TANGGAL JAM TINDAKAN KEPERAWATAN
TANGAN
E. EVALUASI
DIAGNOSA
NO
KEPERAWATAN
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Mengetahui,
Pembimbing Klinik Mahasiswa

(.......................................................) (............................................................)
NIM.