PENGKAJIAN KEPERAWATAN ANAK

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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NCHS
a. BB/U
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b. TB/U
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c. BB/TB
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d. CDC 2000
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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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5. Obat-Obatan
No Obat
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Indikasi
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6. Hasil Laboratorium
Jam: Tanggal:
NILAI
PEMERIKSAAN HASIL SATUAN METODA
RUJUKAN
HEMATOLOGI
Hemoglobin 14.00-18.00 g/dl Colorimetric
Leukosit 4.0 – 10.5 ribu/ul Impedance
Eritrosit 4.10 – 6.00 Juta/ul Impedance
Analyzer
Hematokrit 42.00 – 52.00 Vol%
Calculates
Trombosit 150 – 450 Ribu/ul Impedance
Analyzer
RDW-CV 12.1 – 14.0 %
Calculates
MCV,MCM, MCHC
Analyzer
MCV 75.0-96.0 fl
Calculates
Analyzer
MCH 28.0-32.0 Pg
Calculates
Analyzer
MCHC 33.0-37.0 %
Calculates
HITUNG JENIS
Basofil% 0.0-1.0 %
Eosinofil% 1.0-3.0 %
Gran% 50.0-81.0 % Impedance
Limfosit% 20.0-40.0 % Impedance
Monosit% 2.0-8.0 % Impedance
Basofil# <1.00 Ribu/ul
Eosinofil# <3.00 Ribu/ul
Gran# 2.50-7.00 Ribu/ul Impedance
Limfosit# 1.25-4.0 Ribu/ul Impedance
Monosit# 0,30-1,00 Ribu/ul Impedance
Retikulosit% 0.5-1.5 %
Retikulosit# 25000-75000 /ul METODA 2
KIMIA
HATI
SGOT 0-46 U/l IFCC
SGPT 0-45 U/l IFCC
GINJAL
 Ureum 10-50 mg/dl Modif-Berhelot
Creatinin 0,6-1,2 mg/dl Jaffe

VII. PEMERIKSAAN FISIK

1. Keadaan Umum:
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2. Kesadaran : .......................................................................................................
- 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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ANALISIS DATA
Nama Klien : ..............................................
Umur : ..............................................
Ruangan/Kamar : ..............................................
No. Data Penyebab Masalah
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 PRIORITAS MASALAH
Nama klien : ..............................................
Umur : ..............................................
Ruangan/kamar : ..............................................
No. RM : ..............................................
Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama Perawat)
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No. Diagnosa Keperawatan
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RENCANA KEPERAWATAN
Tujuan Dan
Kriteria Hasil
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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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