ASUHAN KEPERAWATAN PADA ........................................

DENGAN DIAGNOSA MEDIS ...........................................................

DI ...............................................................................................
TANGGAL…………………………………………………………………………

I. PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama : .........................................................................................
Umur : .........................................................................................
Agama : .........................................................................................
Jenis Kelamin : ...........................................................................................
Status : ...........................................................................................
Pendidikan :............................................................................................
Pekerjaan : ............................................................................................
Suku Bangsa :............................................................................................
Alamat : ..........................................................................................
Tanggal Masuk : ...........................................................................................
Tanggal Pengkajian : ...........................................................................................
No. Register : .............................................................................................
Diagnosa Medis : ............................................................................................

b. Identitas Penanggung Jawab

Nama : ............................................................................................
Umur : .............................................................................................
Hub. Dengan Pasien : ...........................................................................................
Pekerjaan : .............................................................................................
Alamat : ..............................................................................................

c. Identitas saudara kandung

No Nama Usia Hubungan Keterangan

2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................

2) Alasan masuk rumah sakit dan perjalanan penyakit saat ini

..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................

3) Upaya yang dilakukan untuk mengatasinya

..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................

b. Riwayat kesehatan lalu

(khusus untuk anak usia 0-5 tahun)
1. Pre natal care
a. Mulai melakukan pearwatan sejak kapan
....................................................................................................................................
....................................................................................................................................
.....................................................................
b. Keluhan ibu saat hamil ?
....................................................................................................................................
....................................................................................................................................
.....................................................................

c. Riwayat sinar X?
 ....................................................................................................................................
....................................................................................................................................
.....................................................................
d. Kenaikan BB saat hamil?
....................................................................................................................................
....................................................................................................................................
.....................................................................
e. Imunisasi?
....................................................................................................................................
....................................................................................................................................
.....................................................................
f. Goldar ibu dan ayah?
2. Natal
a. Tempat melahirkan?
....................................................................................................................................
....................................................................................................................................
.....................................................................
b. Lama dan jenis persalinan?
....................................................................................................................................
....................................................................................................................................
.....................................................................
c. Penolong persalinan?
....................................................................................................................................
....................................................................................................................................
.....................................................................
d. Cara memudahkan persalinan?
....................................................................................................................................
....................................................................................................................................
.....................................................................
3. Post natal
a. Kondisi
bayi(BB,PB) : ............................................................................................................
b. Keadaan anak setelah 28 hari : ..................................................................................
c. Masalah kesehatan pada bayi : ..................................................................................
(untuk semua usia)
1. Penyakit yang pernah dialami : .......................................................................................
2. Riwayat kecelakaan/keracunan :
...................................................................................................
 3. Prosedur operasi/perawatan RS :
.................................................................................................................................
4. Alergi : ............................................................................................................................
5. Pengobatan dini(konsumsi obat-obatan bebas) :
............................................................................................................................
a. Riwayat kesehatan keluarga
1. Penyakit anggota keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
............................................................................................................

2. Genogram

b. Riwayat imunisasi

No Jenis imunisasi Waktu pemberian Reaksi setelah pemberian

c. Riwayat tumbuh kembang

1. Pertumbuhan fisik
 BB (lahir,masuk RS) : .........................................................................................
 TB(Lahir,masuk RS) : .........................................................................................
 Waktu tumbuh dan tanggalnya gigi : ..................................................................
2. Perkembangan tiap tahap
Usia anak saat 3 bulan
 Berguling : ..........................................................................................................
 Duduk : ...............................................................................................................
 Merangkak : ........................................................................................................
 Berdiri : ...............................................................................................................
 Berjalan : .............................................................................................................
 Senyum kepada orang lain : ................................................................................
 Bicara pertama kali : ...........................................................................................
 Berpakaian tanpa bantuan : .................................................................................
d. Riwayat nutrisi
1. Pemberian ASI
 a. Pertama kali di susui : ..............................................................................................
b. Waktu dan cara pemberian : .....................................................................................
c. Lama pemberian : ..................................................................
d. ASI diberikan hingga usia : ..................................................................
2. Pemberian susu tambahan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
................................
3. Pemberian makanan tambahan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
................................
4. Pola perubahan nutrisi tiap tahapan usia sampai nutrisi saat ini

Usia Jenis nutrisi Lama pemberian

e. Riwayat psychososial
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
........
f. Riwayat spiritual
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
........
g. Reaksi hospitalisasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
........
h. Pemahaman keluarga tentang sakit dan rawat inap
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
 ................................................................................................................................................
........
i. Pemahaman anak tentang sakit dan rawat inap
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
........

j. Aktivitas sehai-hari
1. Nutrisi
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
................................
2. Cairan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
................................
3. Eliminasi
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
................................
4. Istirahat tidur
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
................................
5. Olahraga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
................................
6. Personal hygiene
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 ..........................................................................................................................................
................................

7. Reaksi
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
................................

k. Keadaan fisik
1. Keadaan umum : ..................................................................................
2. Tanda-tanda vital : ..................................................................................
3. Antropometri
PB : ..................................................................................
BB : ..................................................................................
LILA : ..................................................................................
Ling. Kpla : ..................................................................................
Ling. Dada : ..................................................................................
Ling. Perut : ..................................................................................
4. Sistem pernafasan : ..................................................................................
l. Sistem pernafasan
Hidung : ..................................................................................
Leher : ..................................................................................
Dada : ..................................................................................
m. Sistem kardiovaskuler
Konjungtiva : ..................................................................................
Detak jantung : ..................................................................................
Suara jantung : ..................................................................................
Capillary refill time : ..................................................................................
n. Sistem pencernaan
Sklera : ..................................................................................
Mulut : ..................................................................................
Gaster : ..................................................................................
Abdomen : ..................................................................................
Anus : ..................................................................................
o. Sistem indera
Mata : ..................................................................................
Hidung : ..................................................................................
Telinga : ..................................................................................
p. Sistem syaraf
 1. Fungsi Cranial : ..................................................................................
2. Fungsi motorik : ..................................................................................
3. Fungsi sensorik : ..................................................................................
4. Fungsi cerebellum : ..................................................................................
5. Reflek : ..................................................................................
6. Sistem muskuluskeletal : ..................................................................................
7. Sistem integumen : ..................................................................................
8. Sistem endokrin : ..................................................................................
9. Sistem perkemihan : ..................................................................................
10. Sistem imun : ..................................................................................
q. Test diagnostik
1. Laboratorium
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
................................
2. Photo rongent
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
...............................
r. Terapi saat ini
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
........

ANALISA DATA

No Sysmtom Etiologi problem

DIANGNOSA KEPERAWATAN YANG MUNCUL

1.

2.

3.

PERENCANAAN KEPERAWATAN
NO PRIORITAS DIAGNOSA NOC NIC RASIONAL
IMPLEMENTASI

NO NO HARI/TGL JAM IMPLEMENTASI RESPON TTD

DX
EVALUASI

NO NO DX HARI/TGL/JAM EVALUASI TTD