ASUHAN KEPERAWATAN

PADA An/By ……… DENGAN ………………………..

DI RUANG ANGGREK RSUD SALATIGA

Tgl/Jam MRS : ……………………………..

Tanggal/Jam Pengkajian : ……………………………..
Metode pengkajian :.……………………………..
Diagnosa Medis : ……………………………..
No. Registrasi : ……………………………..

I. Kasus Asuhan Keperawatan

A. Pengkajian
a. IDENTITAS KLIEN
Nama : ................................................................
Tempat/ tgl lahir : ................................................................
Umur : ................................................................
Pendidikan : ................................................................
Alamat : ................................................................
Agama : ................................................................
Nama Ayah/Ibu : ................................................................
Pekerjaan ayah : ................................................................
Pekerjaan ibu : ................................................................
Pendidikan ayah : ................................................................
Pendidikan ibu : ................................................................
Agama : ................................................................
Alamat : ................................................................
Suku bangsa : ................................................................
b. KELUHAN UTAMA
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c. RIWAYAT PENYAKIT SEKARANG

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d. RIWAYAT MASA LAMPAU

a. Prenatal
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b. Natal
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c. Post natal
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d. Pernah dirawat di RS : ...........................................................................

Penyakit yang diderita: ..........................................................................
Respon emosional waktu dirawat:
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e. Obat-obatan yang digunakan

Pernah atau sedang digunakan:
Nama Dosis Jadwal Durasi Alasan
pemberian penggunaan

f. Alergi : ...........................................................................
g. Kecelakaan : ...........................................................................
Jenis kecelakaan : ...........................................................................
Akibat dan penanganannya:
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 h. Immunisasi
Imunisasi Usia Reaksi imunisasi

e. RIWAYAT KELUARGA
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Genogram
f. RIWAYAT SOSIAL
a. Yang mengasuh
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b. Pembawaan anak secara umum
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c. Lingkungan rumah
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g. KEADAAN KESEHATAN SAAT INI (dari rumah sampai saat dikaji)

a. Diagnosa medis : ...........................................................................
b. Tindakan operasi : ...........................................................................
c. Obat-obatan : ...........................................................................
d. Tindakan keperawatan
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e. Hasil laboratorium : ...........................................................................
f. Hasil rontgen : ...........................................................................
g. Data tambahan : ...........................................................................
h. PENGKAJIAN POLA FUNGSIONAL MENURUT GORDON
a. Pola persepsi kesehatan dan manajemen kesehatan
1). Status kesehatan anak sejak lahir
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2). Pemeriksaan kesehatan secar rutin:
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3). Praktek pencegahan kesehatan:
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b. Pola nutrisi-metabolik
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c. Pola eliminasi
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d. Pola istirahat-tidur
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e. Pola persepsi-kognitif
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f. Pola persepsi diri-konsep diri
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 h. pola peran-hubungan
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i. Pola seksualitas
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j. Pola koping-toleransi terhadap stress
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k. Pola nilai-keyakinan
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i. PEMERIKSAAN FISIK
a. KeadaanUmum : baik/cukup/lemah
1). Kesadaran : ……………………………………
2). Tanda-Tanda Vital
a) Nadi
- Frekuensi : ……………………………………
- Irama : ……………………………………
- Kekuatan : ……………………………………
b) Pernafasan
- Frekuensi : ……………………………………
- Irama : ……………………………………
c) Suhu : ……………………………………
d) Antropometri
BB : ……………………………………
PB : ……………………………………
LK : ……………………………………
LD : ……………………………………
e) Reflek
Moro Tonik leher
Menggenggam Neck-righting
Menghisap Reflek Gallant
b. Pemeriksaan Head To Toe
1). Kepala
a) Bentuk dan ukuran kepala
b) Gambaran wajah
c) Kulit kepala
d) Sutura sagitalis
e) Molding
: ………………………………...
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2). Muka
a) Mata
- Kebersihan : ………………………………...
- Fungsi penglihatan : ………………………………...
- Palpebra : ………………………………...
- Konjungtiva : ………………………………...
- Sclera : ………………………………...
- Pupil : ………………………………...
- Diameter ki/ka : ………………………………...
- Reflek Terhadap Cahaya : ………………………………...
- Penggunaan alat bantu penglihatan: …………………………...
b) Hidung
- Bentuk : ………………………………...
- Sekret : ………………………………...
- Nyeri sinus : ………………………………...
- Polip : ………………………………...
- Napas Cuping hidung : ………………………………...
c) Mulut
- Bentuk : ………………………………...
- Palatum : ………………………………...
- Selaput mukosa : ………………………………...
- Warna lidah : ………………………………...
d) Telinga
- Fungsi pendengaran : ………………………………...
- Bentuk : ………………………………...
- Kebersihan : ………………………………...
- Serumen : ………………………………...
3). Leher
a) Bentuk : ………………………………...
b) Pembesaran tyroid : ………………………………...
c) Kelenjar getah bening : ………………………………...
 d) JVP : ………………………………...
4). Dada (Thorax)
a) Paru-paru
- Inspeksi : ………………………………...
- Palpasi : ………………………………...
- Perkusi : ………………………………...
- Auskultasi : ………………………………...
b) Jantung
- Inspeksi : ………………………………...
- Palpasi : ………………………………...
- Perkusi : ………………………………...
- Auskultasi : ………………………………...
c) Abdomen
- Inspeksi : ………………………………...
- Auskultasi : ………………………………...
- Perkusi : ………………………………...
- Palpasi : ………………………………...
d) Genetalia : ………………………………...
e) Anus dan rectum: ……………………………...
f) Ekstremitas
1) Atas
- Kekuatan otot kanan dan kiri : ………………………
- ROM kanan dan kiri : ………………………
- Perubahan bentuk tulang : ………………………
- Pergerakan sendi bahu : ………………………
- Perabaan Akral : ………………………
- Pitting edema : ………………………
- Terpasang infus : ………………………
2) Bawah
- Kekuatan otot kanan dan kiri : ………………………
- ROM kanan dan kiri : ………………………
- Perubahan bentuk tulang : ………………………
- Varises : ………………………
- Perabaan Akral : ………………………
- Pitting edema : ………………………
g) Integumen
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j. PEMERIKSAAN PERKEMBANGAN (penilaian berdasarkan format
DDST/ DENVER II) bagi anak usia 0 – 6 th