BAB III

PROSES ASUHAN KEPERAWATAN

I. PENGKAJIAN
A. Data Demografi
1. Klien/Pasien
a. Tanggal pengkajian : ...................................
b. Tanggal masuk : ...................................
c. Ruangan : ..................................
d. Identitas
 Nama : ...................................
 Tanggal lahir/umur: ................................
 Jenis kelamin : ...................................
 Agama : ...................................
 Suku : ...................................
 Diagnosa medis : ...................................
 Penanggung jawab: ...............................

2. Orang Tua/ Penanggung Jawab

a. Nama : ………………………...
b. Hubungan dengan klien : …………………………
c. Suku : ………………………...
d. Agama : …………………………
e. Alamat : …………………………
....................................
f. No. telepon : ………………….........

B. Riwayat Klien
1. Keluhan utama saat ini :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
....
Riwayat penyakit klien sebelum masuk rumah sakit
: ............................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..................
2. Riwayat sakit sebelumnya :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 ..........................................................................................................................................
..........................................................................................................................................
....

3. Riwayat kehamilan (ANC, masalah kesehatan selama kehamilan, dll) :

..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
....
4. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit
persalinan, dll):
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
...

5. Riwayat imunisasi (lengkapi)

 Hepatitis B I  BCG
 Hepatitis B II  Hepatitis B III
 Polio I  Polio II
 Polio III  Polio IV
 DPT I  DPT II
 DPT III  Campak
 LAINNYA,sebutkan…….......................................
6. Riwayat alergi : …………….................................

7. Riwayat pemakaian obat-obatan :

..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
.

8. Riwayat tumbuh kembang (Sejak lahir hingga sekarang):

Motorik halus:

Motorik kasar:
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 ..........................................................................................................................................
....
Bahasa :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Personal sosial
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

C. Riwayat Kesehatan Keluarga

1. Riwayat penyakit dalam keluarga:
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

2. Genogram

Keterangan gambar :
: laki-laki : klien

: perempuan : meninggal

: tinggal dalam satu rumah

D. Riwayat Penyakit sekarang
1. Penampilan umum
a. Keadaan umum (kondisi klien secara umum):
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
..........................................................

b. Pemeriksaaan Tanda-Tanda Vital

1) Pernapasan : ....................
2) Suhu : .....................
3) Nadi : .....................
4) Tekanan Darah : ...................
5) Saturasi oksigen : ..................
c. Penggunaan alat bantu napas (Oksigen, dll)
.................................................................................................................................
..........................................................................................................................

2. Nutrisi dan cairan:

a. Lingkar Lengan atas :..................cm
b. Panjang badan/tinggi badan : ................cm
c. Berat badan : ..................kg
d. Lingkar kepala: ..................cm
e. Lingkar dada : ..................cm
f. Lingkar perut : ...................cm
g. Status nutrisi (z-score atau WHO, CDC) :
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
............................................................................
h. Kebutuhan Kalori :
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
........

i. Jenis makanan: ..........................................................

Makanan yang disukai :
 ..............................................................................................................................
..............................................................................................................................
..........................................................................................................................
Alergi makanan :
...........................................................................................................................
j. Kesulitan saat makan :
..............................................................................................................................
.......................................................................................................................
k. Kebiasaan khusus saat makan:
..............................................................................................................................
..............................................................................................................................
.........................................................................................................................

l. Keluhan (mual, muntah, kembung, anoreksia, dsb...):

..............................................................................................................................
..............................................................................................................................
..........................................................................................................................

m. Kebutuhan cairan 24 jam :

a. Balance cairan (hitung jumlah dan jenis cairan masuk dan keluar):
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
......................................................................................................................

b. Diuresis :
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
...
c. Rute cairan masuk (oral, parenteral, enteral, dsb)
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
 d. Jenis cairan (ASI/susu formula/infus/air putih, dsb):
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
e. Keluhan :
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................

3. Istirahat tidur
a. Lama waktu tidur (24 jam) : ……… jam
b. Kualitas tidur :……………..
c. Tidur siang (ya/tidak)
d. Kebiasaan sebelum tidur : ..........................................

4. Pengkajian nyeri (sesuai usia, lampirkan alat ukur):

5. Pemeriksaan Fisik (Head to toe)

a. Keadaan umum
........................................................................................................................
........................................................................................................................
b. Kesadaran
Tingkat Respon Respon
Respon mata Nilai GCS
kesadaran motorik Verbal

c. Vital sign
Capillary
Tanggal TD Nadi RR Suhu
Refill
 d. Kepala

Inspeksi

Palpasi

e. Mata

Inspeksi

Palpasi

f. Hidung

Inspeksi

Palpasi

g. Mulut

Inspeksi

Palpasi

h. Telinga
Inspeksi
 Palpasi

i. Leher

Inspeksi

Palpasi

j. Paru-paru

Inspeksi

Palpasi

Perkusi

Auskultasi

k. Jantung
Inspeksi

Palpasi

Perkusi

Auskultasi

l. Abdomen

Inspeksi

Auskultasi

Perkusi
 Perkusi

m. Genitalia

Inspeksi

Palpasi

n. Ekstremitas Atas
Kanan Kiri
Baal Nyeri Edema Lemas Baal Nyeri Edema Lemas

Kekuatan otot : Kiri ( ), Kanan ( )

o. Ekstremitas bawah
Kanan Kiri
Baal Nyeri Edema Lemas Baal Nyeri Edema Lemas

Kekuatan otot : Kiri ( ), Kanan ( )

6. Psikososial anak dan keluarga

a. Respon hospitalisasi (rewel, tenang)
............................................................................................................................
............................................................................................................................
............................................................................................................................
b. Kecemasan (anak dan orang tua)
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................

c. Koping klien/keluarga dalam menghadapi masalah

............................................................................................................................
............................................................................................................................
............................................................................................................................
...........................................................................................................................
d. Pengetahuan orang tua tentang penyakit anak
............................................................................................................................
............................................................................................................................
........................................................................................................................

e. Keterlibatan orang tua dalam perawatan anak

............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
f. Konsep diri
- Gambaran Tubuh
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
...
- Ideal Diri
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
...
- Harga Diri
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
...
- Peran
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
...
- Identitas Diri
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................

g. Spiritual (kebiasaan ibadah, keyakinan, nilai, budaya)

 ............................................................................................................................
............................................................................................................................
........................................................................................................................

h. Adakah terapi lain selain medis yang dilakukan

............................................................................................................................
............................................................................................................................
........................................................................................................................

7. Pemeriksaan penunjang (laboratorium, radiologi)