PENGKAJIAN KEPERAWATAN ANAK

Tanggal Pengkajian : 18 November 2019

DATA IDENTITAS KLIEN

Nama : An. Aril
Tempat / Tanggal lahir : Desa Rubai / 5 April 2005
Nama Ayah/lbu : Tn . Deno
Pekerjaan Ayah : Swasta
Pendidikan Ayah : SMP
Pekerjaan lbu : ..................................................................................
Pendidikan Ibu : ..................................................................................
Alamat : Desa Rubai Kec. muara Teweh Kab. Barito Utara,
Kalimantan Tengah
Kultur : Dayak
Agama : Hindu
Diagnosis Medis : Susp SLE + Arthritis idiopatik juvenil + Sindrom
nefrotik
Tanggal MRS/rawat inap : 18 November 2019

I. KELUHAN UTAMA
a. Keluhan Masuk Rumah Sakit
Ayah pasien mngatakan pasien dibawa ke RSUD Ulin Banjarmasin berdasarkan
rujukan dari RS Muara Teweh
b. Keluhan Saat ini
Pasien mengeluhkan bengkak pada bagian wajah serta nyeri pada bagian
persendian.
P: Arthritis idiopatik juvenil, nyeri timbul jika efek obat telah habis
Q: Nyeri yang dirasakan ngilu, nyeri jarang terjadi
R: Bagian persendian tanpa menjalar ke bagian lain
S: Skala nyeri 3 (0-10), sedikit menganggu aktivitas
T: Ketika efek obat habis dan bertambah saat cuaca dingin

II. RIWAYAT KESEHATAN

a. Riwayat penyakit sekarang:
Ibu pasien mengatakan 1 bulan SMRS RSUD Ulin Banjarmasin anaknya dirawat di
RS Muara Teweh selama 1 minggu dengan keluhan awal pengelupasan pada
 telapak kaki, wajah hingga bagian telinga. Ibu pasien juga mengatakan kedua kaki
anaknya sempat bengkak dan tidak dapat berjalan, setelah diberikan obat di RS
muara teweh bengkak pada kaki hilang dan anak dapat berjalan kembali. Dari RS
muara teweh pasien dirujuk ke RSUD Ulin Banjarmasin untuk melanjtkan
pemeriksaan dan pengobatan, namun karna terdapat kendala pasien dibawa ke
RSUD Ulin Banjarmasin setelah 3 minggu keluar dari rumah sakit Muara Teweh.
Selama 3 minggu dirumah pasien diberikan obat methil prednisolon dan zat besi.
Pasien dibawa ke RSUD Ulin Banjarmasin pada tanggal 18 November 2019.
b. Riwayat penyakit dahulu
Ibu pasien mengatakan sebelumnya anaknya belum pernah dirawat dirumah sakit. Namun
ibu pasien mengatakan anaknya mengalami sakit pada bagian sendi sejak usia 10 tahun
mamun tidak pernah dibawa kontrol ke pelayanan kesehatan karena penyakit hilang
timbul dan sakit yang dirasakan hanya sebentar.
III. RIWAYAT IMUNISASI
Ibu pasien mengatakan anaknya sudah melakukan imunisasi lengkap.

IV. RIWAYAT PENYAKIT KELUARGA

Ayah pasien mengatakan tidak ada keluarga yang memiliki riwayat penyakit seperti
anaknya, riwayat hiprtensi (-), diabetes mellitus (-), penyakit jantung (-), penyakit
ginjal (-), penyakit paru (-)

GENOGRAM
Keterangan:
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V. RIWAYAT SOSIAL
1. Sistem pendukung/ keluarga terdekat yang dapat dihubungi
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2. Lingkungan rumah
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3. Problem sosial yang penting
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VI. KEADAAN KESEHATAN SAAT INI

1. Tindakan Operasi
Ibu pasien mengatakan anaknya tidak pernah dilakukan operasi.
2. Status Nutrisi
Ibu pasien mengatakan nafsu makan pasien menurun dalam 1 minggu terakhir
pasien hanya dapat mengahabiskan setengah dari porsi makanan yang ada. Pasien
mengatakan tidak terdapat mual dan muntah.
3. Status Cairan:
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4. Aktivitas Anak
Sebelum Masuk Rumah Sakit:
Pasien mengatakan aktivitas sehari-hari adalah sekolah dan bermain bersama
dengan teman-teman.
Saat Dirawat Di Rumah Sakit:
Pasien mengatakan hanya berjalan-jalan disekitar ruangan, tidak dapat sekolah dan
tidak dapat bermain dengan teman-temannya.
5. Obat-Obatan
(Terlampir)
6. Hasil Laboratorium
(Terlampir)
7. Pemeriksaan Penunjang
Hasil Pemeriksaan

Keterangan:
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VII. PEMERIKSAAN FISIK
1. Keadaan Umum:
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2. Kesadaran : Compos Mentis
 Tanda Vital : .......................................................................................................
 Nadi : x/ menit
 Suhu : °C
 RR : x/ menit
3. Pengkajian Skala Nyeri

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4. Kepala dan Leher
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5. Mata
Posisi bola mata : ...........................................................................................
Gerakan mata : ...............................................................................................
Konjungtiva : .............................................................................................................
Kornea : .....................................................................................................................
Sklera : ......................................................................................................................
Pupil :.........................................................................................................................
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6. THT
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7. Ekstremitas
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8. Toraks
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9. Jantung
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10. Abdomen
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11. Genitalia
Frekuensi BAK: ......................../hari , Jumlah Urine: ........................ cc
Warna Urine: .............................................................................................................
Penggunaan Alat bantu berkemih: ............................................................................
Kondisi Blast: ............................................................................................................
Tanggal defekasi terakhir: .........................................................................................
Frekuensi BAB: .........../hari, Konsistensi: ..............., Warna: ......................
Penggunaan Alat bantu (Laksatif): ............................................................................
12. Tumbuh Kembang
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Lampiran 1. Daftar Obat-Obatan
No Obat Dosis Indikasi
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Lampiran 2. Hasil Pemeriksaan Laboraturium

Pemeriksaan Hasil Nilai Normal Satuan
HEMATOLOGI
Hemoglobin ................. 10.00-17.00 g/dl
Lekosit ................. 4.0-10.5 ribu/ul
Eritrosit ................. 3.40-5.50 juta/ul
Hematokrit ................. 35.00-50.00 vol%
Trombosit ................. 150-450 ribu/ul
RDW-CV ................. 11.5-14.7 %
MCV,MCH, MCHC
MCV ................. 80.0 – 97.00 fl
MCH ................. 27.0 – 32.0 pg
MCHC ................. 32.0 – 38.0 %
HITUNG JENIS
Gran% ................. 50.0 – 70.0 %
Limfosit% ................. 25.0 – 40.0 %
MID% ................. 4.0-11.0 %
Gran# ................. 2.50 – 7.00 ribu/ul
Limfosit# ................. 1.25-4.0 ribu/ul
MID# ................. ribu/ul
KIMIA DARAH
Glukosa Darah Sewaktu ................. <200 mg/dl
HATI
SGOT ................. 0-46 u/l
SGPT ................. 0-45 u/l
GINJAL
Ureum ................. 10-50 mg/dl
Kreatinin ................. 0.7-1.4 mg/dl
ELEKTROLIT
Natrium ................. 135-146 mmol/l
Kalium ................. 3.4-5.4 mmol/l
Chlorida ................. 95-100 mmol/l
 ANALISIS DATA
Nama Klien : ..............................................
Umur : ..............................................
Ruangan/Kamar : ..............................................
No. Data Penyebab Masalah
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 PRIORITAS MASALAH
Nama klien : ..............................................
Umur : ..............................................
Ruangan/kamar : ..............................................
No. RM : ..............................................
No. Masalah Keperawatan
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Tanggal
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Paraf
(Nama Perawat)
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No. Diagnosa Keperawatan
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RENCANA KEPERAWATAN
Tujuan Dan
Kriteria Hasil
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Rasional
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 IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN
No.
Waktu
Dx Implementasi
Tgl/jam
Kep
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Waktu
TT Evaluasi TT
Tgl/jam
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