Format Asuhan Keperawatan Anak

PRODI PENDIDIKAN PROFESI NERS

FAKULTAS ILMU KESEHATAN
INSTITUT ILMU KESEHATAN
BHAKTI WIYATA KEDIRI

PENGKAJIAN KEPERAWATAN ANAK

Pengkajian tanggal : Jam :

Tanggal MRS : No. RM :
Ruang/Kelas : Dx. Masuk :

I. IDENTITAS
Identitas anak Identitas Orang Tua
Nama : Nama ayah / ibu :
Tanggal lahir : Pekerjaan ayah / ibu :
Jenis kelamin : Pendidikan ayah / ibu :
Diagnosa medis : Agama :
Sumber informasi : Suku / bangsa :
Alamat : Alamat :

II. RIWAYAT SAKIT DAN KESEHATAN

Keluhan utama : ............................................................................................................
Riwayat penyakit saat ini :
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Riwayat kesehatan sebelumnya :
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Penyakit yang pernah diderita :
Demam Kejang Batuk pilek
Mimisan Lain-lain : …………………………
Operasi : Ya Tidak Tahun : …………………………
Alergi :
Makanan Obat Udara
Debu Lainnya, sebutkan : …………………….
Imunisasi :
BCG(umur ……) Polio ……x (umur ……)
DPT ……x (umur ……) Campak (umur ……)
Hepatitis ……x (umur ……)
Riwayat kesehatan keluarga :
Penyakit yang pernah diderita keluarga : ...............................................................
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Lingkungan rumah dan komunitas : .......................................................................
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Perilaku yang mempengaruhi kesehatan : ..............................................................
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Persepsi keluarga terhadap penyakit anak : ...........................................................
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Riwayat nutrisi :
Sebelum MRS Selama MRS
Baik Baik
Nafsu makan
Tidak Tidak
Pola makan …………x/hari …………x/hari
Jenis : ……………. Jenis : ……………
Minum Jumlah : ……...cc/hari Jumlah :…..…cc/hari

Menu makanan

Pantangan makanan : .....................................................................................................

Riwayat pertumbuhan :
BB saat ini : ……Kg TB : ……cm LK : ……cm
LLA : ……cm BB lahir : ……gram
BB sebelum sakit : ……Kg
Panjang lahir : ……cm
Keterangan : ..................................................................................................................
Riwayat perkembangan :
Pengkajian perkembangan DDST : .......................................................................
Tahap perkembangan psikososial : .......................................................................
Tahap perkembangan psikoseksual : .......................................................................
Masalah keperawatan : ..................................................................................................

III. PENGKAJIAN NEONATUS

Riwayat kesehatan / kehamilan :
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Nilai APGAR skor :
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Tindakan pertolongan bayi baru lahir :
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Penampilan umum :
Fontanela : Anterior : Posterior :
Palatum : Bibir :
Warna kulit :
Ekstremitas :
Genitalia :
Kelainan yang lain : ......................................................................................................
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Masalah keperawatan : ..................................................................................................

IV. REVIEW OF SYSTEM

Keadaan umum : Baik Sedang Lemah
Kesadaran : Compos mentis Apatis Somnolen
Sopor Koma
Tanda vital : TD : ……mmHg N : ……x/mn
S : ……oC RR : ……x/mnt
Masalah keperawatan : ..................................................................................................

IV. B1 (BREATH)
Bentuk dada : Normal Tidak normal, jenis : ……
Pola nafas : Teratur Tidak teratur
Jenis : Dispnoe Kusmaul Ceyne Stokes
Lain-lain : .............................................................................
Suara nafas : Vesikuler Wheezing Stridor Ronchi
Lain-lain :
Sesak : Ya Tidak
Batuk : Ya Tidak
Produktif : Ya Tidak
Bentuk dada :
Silinder Funnel chest Pigeon chest
Retraksi otot bantu nafas : Ada Tidak ada
ICS Supraklavikular Suprasternal
Substernal Intraklavikula
Alat bantu pernafasan : Ada Tidak ada
Nasal Masker Respirator
Flow : …… Lpm
Lain-lain : ......................................................................................................................
Masalah keperawatan : ...................................................................................................

V. B2 (BLOOD)
Irama jantung : Reguler Ireguler
S1/S2 tunggal : Ya Tidak
Bunyi jantung : Normal Gallop Murmur Lain-lain :
CRT : < 3 dtk > 3 dtk
Akral : Hangat Dingin Kering
Basah Merah Pucat
Lain-lain : ......................................................................................................................
Masalah keperawatan : ..................................................................................................

VI. B3 (BRAIN)
GCS : Eye : Verbal : Motorik : Total :
Refleks fisiologis : Menghisap Menoleh Menggenggam
Moro Patella Triseps
Biseps Lain-lain :
Refleks patologis : Kaku kuduk Babinsky Budzinsky
Kernig Lain-lain :
Istirahat / tidur : …… jam/hari Gangguan tidur :
Kebiasaan sebelum tidur :
Minum susu Cerita/dongeng Mainan
Penglihatan (mata):
Pupil : Isokor Anisokor Lain-lain :
Strabismus
Sclera/konjungtiva : Anemis Ikterus
Lain-lain : ..........................................................................................................
Pendengaran (telinga):
Gangguan pendengaran : Ya Tidak
Jelaskan : ............................................................................................................
Penciuman (hidung):
Bentuk : Normal Tidak Jelaskan :
Gangguan penciuman : Ya Tidak Jelaskan :
Lain-lain: ........................................................................................................................
Masalah keperawatan : ..................................................................................................

VII. B4 (BLADDER)
Kebersihan : Bersih Kotor
Urin : Jumlah : …………. cc/hari Warna : Bau :
Alat bantu (kateter, dll) :
Kandung kemih :
Membesar : Ya Tidak
Nyeri tekan : Ya Tidak
Bentuk alat kelamin : Normal Tidak normal, jelaskan :
Uretra : Normal Hipospadia/Epispadia
Gangguan : Anuria Oliguria Retensi
Inkontinensia Nokturia Lain-lain :
Lain-lain : ......................................................................................................................
Masalah keperawatan : ...................................................................................................

VIII. B5 (BOWEL)
Nafsu makan : Baik Menurun Frekuensi : …….x/hari
Mual Muntah
(Warna : Konsistensi : Jumlah : )
Porsi makan : Habis Tidak habis Keterangan :
Minum : Jumlah : ……………cc/hr Jenis :
Mulut dan tenggorokan :
Mulut : Bersih Kotor Berbau
Mukosa : Lembab Kering Stomatitis
Tenggorokan : Sakit menelan/nyeri tekan
Kesulitan menelan
Pembesaran tonsil
Lain-lain : ...........................................................................................
Abdomen :
Tegang Kembung Asites
Nyeri tekan, Lokasi :
Peristaltik usus : …….x/menit
Pembesaran hepar : Ya Tidak
Pembesaran lien : Ya Tidak
Buang air besar :
Teratur : Ya Tidak
Frekuensi : ……. x/hr
Konsistensi : Bau : Warna :
Lain-lain : ......................................................................................................................
Masalah keperawatan : ..................................................................................................

IX. B6 (BONE)
Kemampuan pergerakan sendi : Bebas Terbatas
Kekuatan otot :

Kepala : Chepal hematome Caput susedanum

Kulit :
Warna : Ikterus Sianosis Kemerahan
Pucat Hiperpigmentasi
Turgor : Baik Sedang Jelek
Odema : Ada Tidak ada Lokasi :
Lain-lain : ......................................................................................................................
Masalah keperawatan : ...................................................................................................

X. ENDOKRIN
Tyroid : Membesar : Ya Tidak
Hiperglikemi : Ya Tidak
Hipoglikemi : Ya Tidak
Luka Gangren : Ya Tidak
Lain-lain : ......................................................................................................................
Masalah keperawatan : ..................................................................................................

XI. PERSONAL HYGIENE

Mandi : …………. x/hr Sikat gigi : …………. x/hr
Keramas : …………. x/hr Memotong kuku : ………….
Ganti pakaian : …………. x/hr
Masalah keperawatan : ..................................................................................................
XII. PSIKO-SOSIO-SPIRITUAL
Ekspresi afek dan emosi : Senang Sedih Menangis
Cemas Marah Diam Takut Lain-lain :
Hubungan dengan keluarga : Akrab Kurang akrab
Dampak hospitalisasi bagi anak : ..................................................................................
Dampak hospitalisasi bagi orang tua : .........................................................................
Masalah keperawatan : ..................................................................................................

XIII. DATA PENUNJANG (LAB, FOTO, USG, DLL)

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XIV. TERAPI / TINDAKAN LAIN

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DAFTAR PRIORITAS MASALAH

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