PENGKAJIAN KEPERAWATAN ANAK

Nama Mahasiswa : Miftahul Jannah

NIM :1830913320008
Kelompok : C1
DATA IDENTITAS KLIEN
Nama : .................................................................................
Tempat / Tanggal lahir :..................................................................................
Nama Ayah/lbu :..................................................................................
Pekerjaan Ayah :..................................................................................
Pendidikan Ayah :..................................................................................
Pekerjaan lbu :..................................................................................
Pendidikan Ibu :..................................................................................
Alamat :..................................................................................
Kultur :..................................................................................
Agama :..................................................................................
Diagnosis Medis : ..................................................................................
Tanggal MRS : ..................................................................................
Tanggal Pengkajian : ..................................................................................

I. KELUHAN UTAMA
a. Keluhan Masuk Rumah Sakit
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b. Keluhan Saat ini
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II. RIWAYAT KESEHATAN
a. Riwayat penyakit sekarang:
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b. Riwayat penyakit dahulu
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III. RIWAYAT IMUNISASI
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IV. RIWAYAT PENYAKIT KELUARGA

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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
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2. Status Nutrisi
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3. Status Cairan:
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4. Aktivitas Anak
Sebelum Masuk Rumah Sakit:
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Saat Dirawat Di Rumah Sakit:
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VII. PEMERIKSAAN FISIK
1. Keadaan Umum:
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2. Kesadaran : .......................................................................................................
- Tanda Vital : .......................................................................................................
- Nadi : x/ menit
- Suhu : °C
- RR : x/ menit
- Pengkajian Skala Nyeri

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3. Kepala dan Leher
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4. Mata
Posisi bola mata : ...........................................................................................
Gerakan mata : ...............................................................................................
Konjungtiva : .............................................................................................................
Kornea : .....................................................................................................................
Sklera : ......................................................................................................................
Pupil :.........................................................................................................................
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5. THT
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6. Ekstremitas
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7. Toraks
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8. Jantung
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9. Abdomen
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10. 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): ............................................................................
11. Tumbuh Kembang
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Lampiran 1. Daftar Obat-Obatan

No Obat Dosis
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Indikasi
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Lampiran 2. Hasil Pemeriksaan Laboratorium

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 %
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MCV,MCH, MCHC
MCV ................ 80.0 – 97.00 fl
MCH . 27.0 – 32.0 pg
MCHC ................ 32.0 – 38.0 %
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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
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KIMIA DARAH
Glukosa Darah Sewaktu ................ <200 mg/dl
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HATI
SGOT ................ 0-46 u/l
SGPT . 0-45 u/l
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GINJAL
Ureum ................ 10-50 mg/dl
Kreatinin . 0.7-1.4 mg/dl
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ELEKTROLIT
Natrium ................ 135-146 mmol/l
Kalium . 3.4-5.4 mmol/l
Chlorida ................ 95-100 mmol/l
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ANALISIS DATA

Nama Klien : ..............................................

Umur : ..............................................
Ruangan/Kamar : ..............................................
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Data Penyebab Masalah
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Nama klien : ..............................................
Umur : ..............................................
Ruangan/kamar : ..............................................
No. RM : ..............................................
No. Masalah Keperawatan
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PRIORITAS MASALAH
Tanggal Paraf
Ditemukan Teratasi (Nama Perawat)
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 RENCANA KEPERAWATAN
Tujuan Dan
No. Diagnosa Keperawatan Intervensi
Kriteria Hasil
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IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN

No.
Waktu Waktu
Dx Implementasi TT Evaluasi TT
Tgl/jam Tgl/jam
Kep
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