ASUHAN KEPERAWATAN GADAR KHUSUS

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Disusun Oleh :
NAMA : ___________________
NIM : ___________________

KEMENTERIAN KESEHATAN RI
FORMAT PENGKAJIAN
POLITEKNIK KESEHATAN KEMENKES MALANG
JURUSAN KEPERAWATAN
PROGRAM STUDI SARJANA TERAPAN
KEPERAWATAN LAWANG
 A. PENGKAJIAN

A1. PENGUMPULAN DATA

I. BIODATA
IDENTITAS ANAK IDENTITAS BAPAK
Nama : __________________ Nama : __________________
No. Register : __________________ Umur : __________________
Umur : __________________ Jenis kelamin : __________________
Jenis kelamin : __________________ Alamat : __________________
Alamat : __________________ Pendidikan : __________________
Suku bangsa : __________________ Pekerjaan : __________________
Tanggal lahir/Umur : __________________ Suku bangsa : __________________
Tgl MRS : __________________ No. Tlp/HP : __________________
Tanggal pengkajian : __________________
Diagnosa medis : __________________ IDENTITAS IBU
Urutan anak : __________________
Nama : __________________
Umur : __________________
Jenis kelamin : __________________
Alamat : __________________
Pendidikan : __________________
Pekerjaan : __________________
Suku bangsa : __________________
No. Tlp/HP : __________________

II. DATA UMUM

a. Berat badan lahir : _________________gram Nadi : __________x/menit
b. Panjang badan lahir : _________________cm Suhu : __________oC
c. Berat badan saat ini : _________________gram RR : __________ x/menit
d. Panjang badan saat ini: _________________cm

III. KELUHAN UTAMA/ALASAN KUNJUNGAN

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IV. RIWAYAT KESEHATAN
A. RIWAYAT PENYAKIT SEKARANG
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B. RIWAYAT KESEHATAN YANG LALU

1) Penyakit-penyakit waktu kecil : ______________________________________________
2) Pernah dirawat di rumah sakit : ______________________________________________
3) Obat-obatan : ____________________________________________________________
4) Tindakan (misalnya : operasi) : ______________________________________________
5) Alergi : _________________________________________________________________
6) Kecelakaan : ____________________________________________________________
7) Imunisasi : ______________________________________________________________
V. Riwayat Keluarga
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VI. Riwayat Sosial
a. Yang mengasuh : ________________________________________________________
b. Hubungan dengan anggota keluarga : ________________________________________
c. Hubungan dengan teman sebaya : ___________________________________________
d. Pembawaan secara umum : ________________________________________________
e. Lingkungan rumah : _______________________________________________________

VII. PEMERIKSAAN FISIK (HEAD TO TOE)

A. Keadaan Umum
Postur : _____________________________________________________________
Kesadaran : ____________________________________________________________
B. Kepala dan rambut
Kebersihan : _______________________________________________________
Bentuk kepala : _______________________________________________________
Keadaan rambut : _______________________________________________________
 Keadaan kulit kepala : caput succedanum, cefalohematom : ______________________
Fontanela anterior : lunak/menonjol/tegas/cekung/datar : _________________________
Sutura sagitalis : tepat/terpisah/menjauh : _____________________________________
Distribusi rambut : merata/tidak merata : ______________________________________
C. Mata
Kebersihan : ____________________________________________________________
Pandangan : ____________________________________________________________
Sclera : _____________________________________________________________
Conjungtiva : ___________________________________________________________
Pupil : _____________________________________________________________
Gerakan bola mata : _____________________________________________________
Sekret : _____________________________________________________________
D. Hidung
Pernafasan Cuping hidung : ________________________________________________
Struktur : _____________________________________________________________
Kelainan lain : polip/perdarahan/peradangan : __________________________________
Sekresi : _____________________________________________________________
E. Telinga
Kebersihan : ___________________________________________________________
Sekresi : _____________________________________________________________
Struktur : ____________________________________________________________
Fistula aurikel : _________________________________________________________
Membran timpani : _______________________________________________________
F. Mulut dan Tengorokan
Jamur (stomatitis, moniliasis) : _____________________________________________
Kelaianan bibir dan rongga mulut (gnato/labio/palato skizis) : _____________________
Problem menelan : ______________________________________________________
G. Leher
Vena jugularis : _______________________________________________________
Arteri karotis : _______________________________________________________
Pembesaran tiroid dan limfe : ______________________________________________
Torticoliis : _______________________________________________________
H. Dada/Thorak (jantung dan Paru)
Bentuk dada : _______________________________________________________
Pergerakan kedua dinding dada : ___________________________________________
Tarikan dinding dada ke atas/bawah : ________________________________________
Suara pernafasan : _______________________________________________________
 Frekwensi nafas : _______________________________________________________
Abnormalitas suara nafas : _________________________________________________
Suara jantung : _______________________________________________________
Kelainan jantung bawaan : _________________________________________________
I. Ekstremitas atas
Tonus otot : _______________________________________________________
Refleks menggenggam : _________________________________________________
Trauma, deformitas : _____________________________________________________
Kelainan struktur : _______________________________________________________
J. Perut
Bentuk perut : _______________________________________________________
Bising usus : _______________________________________________________
Ascites, benjolan : _______________________________________________________
Turgor kulit : _______________________________________________________
Vena : _______________________________________________________
Hepar, lien : _______________________________________________________
Distensi : _______________________________________________________
K. Punggung
Spina bifida : _______________________________________________________
Deformitas : _______________________________________________________
Kelainan struktur : _______________________________________________________
L. Kelamin dan anus
Kebersihan : _______________________________________________________
Keadaan kelamin luar : ____________________________________________________
Anus : _______________________________________________________
Kelainan : _______________________________________________________
M. Ekstremitas bawah
Tonus otot : _______________________________________________________
Trauma, deformitas : _____________________________________________________
Kelainan struktur : _______________________________________________________
N. Integumen
Warna kulit : _______________________________________________________
Kelembaban : _______________________________________________________
Lesi : _______________________________________________________
Warna kuku, rambut : _____________________________________________________
Kelainan : _______________________________________________________
VIII. PENGUKURAN ANTROPOMETRI
Berat badan : _______________________________________________________
Panjang/Tinggi badan: _______________________________________________________
Lingkar kepala : _______________________________________________________
Lingkar dada : _______________________________________________________
Lingkar lengan Atas : _______________________________________________________

IX. RIWAYAT IMUNISASI

Sebutkan imunisasi yang sudah diberikan beserta umur saat diimunisasi
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X. PEMENUHAN KEBUTUHAN DASAR

A. OKSIGEN
Kebutuhan oksigen : _____________________________________________________
Dosis oksigen : _______________________________________________________
Cara pemberian : _______________________________________________________
B. CAIRAN
Kebutuhan cairan dalam 24 jam : ___________________________________________
Jenis cairan yang diberikan : _______________________________________________
Cara/rute pemberian : ____________________________________________________
Balance cairan dalam 24 jam:
Intake : _____________________________________________________________
Output : _____________________________________________________________
IWL : _____________________________________________________________
Kesimpulan : ___________________________________________________________
C. NUTRISI:
Kebutuhan kalori : _______________________________________________________
Bentuk/jenis nutrisi yang diberikan : _________________________________________
Cara pemberian : _______________________________________________________
Frekwensi pemberian : ___________________________________________________
D. ELIMINASI URINE
Volume urine : _______________________________________________________
Warna : _______________________________________________________
Frekwensi : _______________________________________________________
 Cara BAK (spontan/kateter) : ______________________________________________
Kelaianan pemenuhan BAK : ______________________________________________
E. ELIMINASI ALVI
Volume feses : _______________________________________________________
Warna feses : _______________________________________________________
Frekwensi : _______________________________________________________
Darah, lendir dalam feses : ________________________________________________
F. TIDUR
Jumlah jam tidur dalam 24 jam : ____________________________________________
Kualitas tidur (sering terbangun, rewel, tidak bisa tidur) : _________________________
G. PSIKOSOSIAL
Hubungan orangtua dengan bayi: __________________________________________

XI. TANDA-TANDA VITAL

a. Tekanan Darah : _______________________________________________________
b. Denyut Nadi : _______________________________________________________
c. Pernafasan : _______________________________________________________
d. Suhu Tubuh : _______________________________________________________

XII. TERAPI YANG DIPEROLEH PASIEN

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XIII. PEMERIKSAAN TINGKAT PERKEMBANGAN

Motor kasar : _____________________________________________________________
Motor halus : _____________________________________________________________
Adaptasi social : ____________________________________________________________
Bahasa : _____________________________________________________________
XIV. DATA PENUNJANG

Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

A2. ANALISIS DATA

HARI/TGL : ...............................................................................................

KEMUNGKINAN
NO DATA MASALAH
PENYEBAB
B. DIAGNOSA KEPERAWATAN

NAMA & TANDA

NO TANGGAL DIAGNOSA KEPERAWATAN
TANGAN
C. RENCANA TINDAKAN KEPERAWATAN

DIAGNOSA TUJUAN DAN KRITERIA NAMA & TANDA

NO INTERVENSI RASIONAL
KEPERAWATAN HASIL TANGAN
D. IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN

NAMA & TANDA

NO TANGGAL JAM TINDAKAN KEPERAWATAN
TANGAN
E. EVALUASI
DIAGNOSA
NO
KEPERAWATAN
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TANGGAL
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Mengetahui,
Pembimbing Klinik
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Mahasiswa
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NIM. _________________________