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Disusun untuk Memenuhi Tugas Manaskep Keperawatan Anak

Dosen Pembimbing: Ns. Meira Erawati, Msi.Med
Pembimbing Klinik: ............................................

Disusun oleh :

Nama :
NIM :
Kelas :

DEPARTEMEN ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS DIPONEGORO
SEMARANG
2019
Hari / Tanggal Pengkajian : ....................................................................................................
Identitas Pengkaji : ....................................................................................................
A. Data Demografi
1. Klien / Pasien
a. Nama : ....................................................................................................
b. Tgl lahir / usia : ....................................................................................................
c. Jenis kelamin : ....................................................................................................
d. Kwarganegaraan : ....................................................................................................
e. Tanggal masuk : ....................................................................................................
f. Diagnosa medis : ....................................................................................................
2. Orang Tua / Penanggung Jawab
a. Nama : ....................................................................................................
b. Hubungan dengan klien : ..........................................................................................
c. Alamat : ....................................................................................................
d. No. Telepon : ....................................................................................................
B. Riwayat Klien
1. Riwayat Kehamilan
 ANC : ....................................................................................................
 Riwayat penggunaan obat-obatan : ...............................................................
........................................................................................................................
 Lain-lain : ....................................................................................................
........................................................................................................................
2. Riwayat persalinan
a. Usia gestasi : ........................................................................................
b. BB lahir : ........................................................................................
c. Jenis Persalinan : ........................................................................................
d. Indikasi : ........................................................................................
e. APGAR Skor : ........................................................................................
f. Kejadian penting selama proses persalinan :
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
3. Faktor risiko ibu :
 Ketuban pecah dini
 Preeklamsi
 Ibu dengan infeksi
 Lain-lain : ...................................................................................................
4. Riwayat alergi :
 Tidak
 Ya, sebutkan : ................................................................................................
C. Riwayat Kesehatan Keluarga
1. Riwayat penyakit dalam keluarga :
....................................................................................................................................
....................................................................................................................................
2. Genogram

Keterangan gambar:

D. Riwayat Penyakit Sekarang

1. Penampilan umum
a. Keadaan umum (kondisi klien secara umum) :
..............................................................................................................................
..............................................................................................................................
b. Pemeriksaan tanda-tanda vital
 Pernapasan : ......................................... x/mnt
 Suhu : ......................................... oC
 Nadi : ......................................... x/mnt
 TD : ......................................... mmHg
 Saturasi oksigen : ......................................... %
2. Oksigenasi
a. Irama napas
 Reguler
 Irreguler
b. Kedalaman napas
 Dalam
 Dangkal
  Normal
c. Penggunaan alat bantu napas
 Spontan tanpa oksigen
 Spontan dengan oksigen
 Single nasal prong
 Buble CPAP
 Ventilator
 Lainnya : ..................................................................................................
d. Penggunaan oto bantu napas
 Retraksi
 Napas cuping hidung
e. Sianosis
 Ada
 Tidak ada
3. Nutrisi
a. BB : ......................................................... Kg
b. Lingkar lengan atas : ......................................................... cm
c. Panjang badan : ......................................................... cm
d. Lingkar kepala : ......................................................... cm
e. Lingkar dada : ......................................................... cm
f. Kebutuhan kalori : .........................................................
g. Jenis nutrisi :
 Enteral : ............................................................................
 Parenteral : ............................................................................
h. Terpasang OGT :
 Ya
 Tidak
i. Residu OGT : ............................... cc, warna : .........................
4. Cairan
a. Kebutuhan cairan : ............................................................................
b. Jenis minuman :
 ASI
 PASI
 Lainnya, sebutkan :.............................................................................
c. Turgor kulit :
 Baik
 Sedang
 Buruk
d. Bibir :
 Kering
 Lembab
e. Ubun-ubun :
 Cekung
 Cembung
 Normal
 f. Mata
 Cekung
 Normal
g. Capillary Refill Time : ............................................................................
h. Balance Cairan : ............................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
5. Istirahat tidur
a. Status tidur terjaga : ............................................................................
b. Kualitas tidur :
 Baik
 Kurang baik, jelaskan : ............................................................................
..................................................................................................................
6. Aktifitas
a. Gerakan :
 Aktif
 Kurang aktif
b. Tangisan
 Kuat
 Lemah
c. Sistem muskuloskeletal
1) Postur :
 Fleksi
 Ekstensi
2) Tonus otot :
 Normal
 Tidak normal, jelaskan ................................................................
E. Pemeriksaan Head to toe
1. Integumen
a. Suhu
 Teraba hangat  Teraba dingin
b. Warna kulit
 Pucat
 Kuning
 Normal
c. Integritas kulit
 Utuh
 Kemerahan
 Lecet / iritasi
Lokasi : ....................................................................................................
2. Kepala dan leher
a. Tengkorak
 Simetris
  Tidak simetris
kelainan :
 Tidak
 Ya , sebutkan ..........................................................................................
Tulang tengkorak / sutura
 Belum menutup
 Menutup
 Lainnya , sebutkan ...................................................................................
b. Warna dan distribusi rambut :
 Hitam
 Lainnya , sebutkan ...................................................................................
c. Kelopak mata (bentuk dan gerak)
Bentuk :
 Simetris
 Tidak simetris, sebutkan ..........................................................................
Gerak :
 Simetris
 Tidak simetris, sebutkan ..........................................................................
d. Warna konjungtiva :
 Pink
 Pucat
e. Sklera :
 Ikterik
 Normal
f. Pupil :
Reflek cahaya :
 Positif
 Negatif
g. Telinga
Bentuk dan ukuran :
 Simetris
 Tidak simetris
Kebersihan
 Bersih
 Kotor
h. Hidung
Bentuk, terdapat septum defiasi :
 tidak
 ya
i. Leher
Bentuk :
 Normal
 Tidak normal, sebutkan :..........................................................................
3. Dada, paru-paru, dan jantung
a. Pengembangan dada :
  Simetris
 Tidak simetris, kondisi ............................................................................
b. Iktus kordis
 Tidak teraba
 Teraba di ..................................................................................................
c. Taktil fremitus
 Simetris
 Tidak simetris, sebutkan ..........................................................................
d. Suara paru
 Vesikuler
 Bronchi
 Bronchovesikuler
 Ronchi
 Wheezing
e. Suara jantung
 S1 dan S2 murni
 Gallop
 Mur-mur
4. Abdomen
a. Bentuk
 Simetris
 Tidak simetris, jelaskan ..........................................................................
b. Bising usus : ........................................ x/ mnt
c. Lambung
 Timpani
 Hipertimpani
 Lainnya , sebutkan ...................................................................................
d. Hati
 Pekak
 Lainnya, sebutkan ....................................................................................
e. Usus
 Timpani
 Hipertimpani
 Lainnya , sebutkan ...................................................................................
f. Hepar
 Teraba
 Tidak teraba, di ........................................................................................
g. Limpa
 Teraba
 Tidak teraba, di ........................................................................................
h. Buang air besar
Konsistensi
 Padat
 Lunak
 Cair
 Warna
 Khas tinja
 Mekonium
 Lainnya , sebutkan ...................................................................................
5. Alat kelamin
Kelainan
 Tidak ada
 Ada, sebutkan ................................................................................................
Kebersihan
 Bersih
 Kotor
Iritasi
 Ya
 Tidak
6. Ekstremitas
a. Kesimetrisan
 Simetris
 Tidak simetris
b. Kelainan
 Ada
 Normal
c. Akral
 Hangat
 Dingin
d. Udema
 Ya
 Tidak
7. Perkembangan (reflek) :
 Moro
 Menghisap
 Menelan
 Rooting
F. Pengkajian psikososial
1. Respon hospitalisasi
 Tenang
 Rewel
2. Pengetahuan orang tua tentang kondisi bayi : ...........................................................
....................................................................................................................................
3. Kunjungan orang tua terhadap bayi :
 Ibu
 Ayah
4. Interaksi orang tua dan bayi
 Senthan
 Komunikasi
 Kontak mata
 5. Suasana hati orang tua
 Cemas
 Tenang
 Gelisah
G. Data penunjang
1. Pemeriksaan penunjang

2. Pengobatan

Pengkaji

......................................
ANALISA DATA
NO DATA PROBLEM ETIOLOGI
PROBLEM/LIST
NO TGL/JAM DX KEP TTD TGL/JAM TTD
DITEMUKAN TERATASI
RENCANA KEPERAWATAN
NO TGL/ DX KEP INTERVENSI
JAM TUJUAN TINDAKAN TTD
IMPLEMENTASI
NO DX KEP TGL/JAM IMPLEMENTASI RESPON TTD
EVALUASI
NO TGL/JAM DX KEP EVALUASI TTD