KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN JAMBI

PRODI D III JURUSAN KEPERAWATAN
Jl. Dr. Tazar No. 05 Buluran Kenali Telanaipura Jambi 36123 Telp. ( 0741 ) 65816

ASUHAN KEPERAWATAN ANAK

1. TANGGAL PENGKAJIAN :................................... NAMA MAHASISWA :.......................

2. TANGGAL MASUK :................................... NIM :.......................
3. JAM MASUK :................................... TANDA TANGAN :.......................
4. RUANGAN/ KELAS :...................................
5. NOMOR KAMAR :...................................
6. NO. REGISTER :...................................
7. DIAGNOSA MEDIS :...................................

A. PENGKAJIAN
1. IDENTITAS
a. Nama Bayi/ Anak : ........................................................................................
b. Umur :.........................................................................................
c. BeratBadan :......................Kg
Tinggi Badan :......................cm
Lingkar kepala : .....................cm
Lingkar Dada :......................cm
d. Nama Ayah :.........................................................................................
e. Umur :.........................................................................................
f. Pendidikan :.........................................................................................
g. Pekerjaan :.........................................................................................
h. Agama :.........................................................................................
i. Alamat :.........................................................................................
j. NamaIbu :.........................................................................................
k. Umur :.........................................................................................
l. Pendidikan : ........................................................................................
m. Pekerjaan :.........................................................................................
n. Agama :.........................................................................................
o. Alamat :.........................................................................................

2. Alasanmasuk RS .......................................................................................:

3. KeluhanUtama / Chief Complain :.........................................................................

(Saat pengkajian) ………………………………………………...

4. Riwayat Kesehatan Sekarang ( PQRST ) : .........................................................................

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5. Riwayat Kesehatan Yang lalu : ……………………………………………….
a. Penyakit waktu kecil/yang lalu : ……………………………………………….
b. Pernah dirawat (hospitalisasi) : ……………………………………………….
c. Obat-obatan : ……………………………………………….
d. Operasi : ……………………………………………….
e. Alergi : ……………………………………………….
f. Kecelakaan : ……………………………………………….
g. Lain-lain : ……………………………………………….

6. Riwayatpenyakitkeluarga
a. Penyakit yang pernah di derita keluarga: ……………………………………………….
b. Keluarga yang menderita penyakit keturunan; DM,Asthma : ………………………….
c. Keluarga yang menderita penyakit menular; TBC,hepatitis,peny.kulit :……………….
d. Genogram (Minimal 3 generasi)

7. Riwayat Kehamilan dan Persalinan :

Antenatal ( Prenatal ) : ( Usia < 2 thn)
a. Kesehatan Ibu :..........................................................................
b. Berapa kali kunjungan :..........................................................................
c. Adakah dalam pengobatan : ……………………………………………….
- Diet :..........................................................................
- Infeksi :..........................................................................
d. Adakah dilakukan RO :..........................................................................
e. Adakah tanda-tanda Pre eklampsia :..........................................................................
f. Tempat pemeriksaan Kehamilan :..........................................................................
g. KetergantunganObat-obatan :..........................................................................

Natal : ( Usia< 2 thn)

a. UsiaKehamilam :..........................................................................
b. BeratBadanLahir: < 2500 gr  2500 –3000 gr > 3000 gr
c. Jenis dan Lama Persalinan :
 Spontan  Vacum ekstraksi  Induksi  Sectio caesaria
d. KeadaananaksetelahLahir :..........................................................................
- Segera menangis : Ya tidak
- Resusitasi : dilakukan tidak dilakukan
e. Obat yang digunakanselamapersalinan :....................................................................

Neonatal ( Post Natal ) ; Usia 0-28 hari

a. Apgar Score :< 6  6-7  8-10
b. KelainanKongenital :..........................................................................
c. WarnaKulit :
- Cyanosis :..........................................................................
- Kuning/Icterus :..........................................................................
d. Panas :..........................................................................
e. Kejang :..........................................................................
f. Adakah kesulitan dalam menelan, :
menghisap atau minum :..........................................................................
 g. Mengukur Perkembangan
- Motorik Halus
- Motorik Kasar
-Bahasa
- Kemandirian dan sosialisasi
- Lingkar kepala
- Lingkar dada
- Panjang Badan/ Tinggi Badan
- Berat badan
8. KebutuhanDasar
1. Makan (dirumah)
a. JenisMinuman ( ASI/PASI )
b. Interval Minum
c. Waktu yang dibutuhkan untuk minum :.................................................................
d. jumlah minum (Sekali minum)
e. Waktu untuk pengenalan makanan
tambahan
f. Nafsumakan
g. Jenis makanan makanan segar makanan diawetkan Instan
g. Makanan yang disukai
h. Alergi
i. Kebiasaan makan
j. Pantangan
k. Alat yang digunakan
2. Makan (di Rumah Sakit))
a. Jenis Minuman ( ASI/PASI )
b. Interval Minum
c. Waktu yang dibutuhkan untuk minum
d. jumlah minum (Sekali minum)
e. Waktu untuk pengenalan makanan
tambahan
f. Nafsu makan
g. Makanan yang disukai
h. Alergi
i. Kebiasaan makan
j. Pantangan
k. Alat yang digunakan
3. PolaTidur (dirumah)
a. Berapa jam
b. Gangguan saat tidur
c. Hal yang memudahkan tidur
( Boneka/Dongeng/Selimut/Bantaldll )
4. PolaTidur (di rumah sakit)
a. Berapa jam
b. Gangguan saat tidur
c. Hal yang memudahkan tidur
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 (Boneka/Dongeng/Selimut/Bantaldll )

5. Bermain dan Istirahat (dirumah)

a. Berapa jam istirahat :.................................................................
b. Bermain
- Waktu :.................................................................
- Jenis :.................................................................
- Teman :.................................................................
- Tempat :.................................................................
- Hubungandenganteman :.................................................................

6. Bermain dan Istirahat (di rumah sakit)

a. Berapa jam istirahat :.................................................................
b. Bermain
- Waktu :.................................................................
- Jenis :.................................................................
- Teman :.................................................................
- Tempat :.................................................................

7. Hygiene (dirumah)
- Berapa kali mandi :.................................................................
- Berapa kali gosok gigi :.................................................................
- Mandi pakai apa :.................................................................
- Kebersihanrambut / kuku :.................................................................

8. Hygiene (di rumah sakit)

- Berapa kali mandi :.................................................................
- Berapa kali gosok gigi :.................................................................
- Mandipakaiapa :.................................................................
- Kebersihan rambut / kuku :.................................................................

9. Imunisasi
- Dasar< 1 tahun :.................................................................
- Ulangan 1 th – usia sekolah :.................................................................

B. Hasilperkembangan
a. MotorikKasar
Usia 1-4 bln
 Mengangkat kepala saat tengkurap..........................................................Yatidak
 Dapat duduk sebentar dgn ditopang..........................................................yatidak
 Dapat duduk dgn kepala tegak..................................................................yatidak
 Jatuh terduduk dipangkuan ketika disokong saat berdiri.........................Yatidak
 Kontrol kepala dgn sempurna...................................................................yatidak
 Mengangkat Kepala sambil berbaring telentang.......................................yatidak
 Berguling dari telentang kemiring.............................................................yatidak
 Posisi lengan dan tungkai lebih fleksi.......................................................yatidak
 Berusaha untuk merangkak.......................................................................yatidak

Usia 4-8 bln

  Menahan kepala tegak lurus.....................................................................Yatidak
 Berguling dari telentang ke telungkup......................................................yatidak
 Dapat duduk dgn bantuan selama interval singkat...................................Yatidak

Usia 8-12 bln

 Duduk dari tegak tanpa bantuan................................................................yatidak
 Dapat berdiri tegak dgn bantuan..............................................................Yatidak
 Berdiri tegak tanpa bantuan walaupun sebentar.......................................Yatidak
 Membuat posisi merangkak......................................................................yatidak
 Merangkak ............................................................................yatidak
 Berjalan dgn bantuan ...........................................................................Yatidak

b. MotorikHalus
Usia 1 – 4 bln
 Melakukan usaha untuk memegang suatu objek......................................Yatidak
 Mengikuti objek dari sisi ke sisi...............................................................Yatidak
 Mencoba memgang benda tapi terlepas...................................................Yatidak
 Memasukan benda kedalam mulut...........................................................Yatidak
 Memperhatikan tgn dan kaki....................................................................Yatidak
 Memegang benda dan kedua tgn..............................................................Yatidak
 Menahan benda di tgn walaupun sebentar...............................................Yatidak

Usia 4-8 bln

 Menggunakan ibu jari dan jari telunjuk untuk memgang.........................Yatidak
 Mengeksplorasi benda yang sedangdipegang..........................................Yatidak
 Mampu menahan kedua benda dikedua tgn secara simultan....................Yatidak
 Memindahkan objek dari satu tgn ke tgn lain..........................................Yatidak

Usia 8 – 12 bln
 Melepas objek dgn jari lurus....................................................................Yatidak
 Mampu menjepit benda ...........................................................................Yatidak
 Melambaikan tgn ...........................................................................Yatidak
 Menggunakan tangan untuk bermain.......................................................Yatidak
 Menempatkan objek ke dalam wadah......................................................Yatidak
 Makan biscuit sendiri ...........................................................................Yatidak
 Minum dari cangkir dgn bantuan.............................................................Yatidak
 Makan dgn jari ...........................................................................Yatidak

c. Bahasa :..........................................................................

C. Pemeriksaan fisik
a. Tanda-tanda vital
- Tekanan Darah ……..mmHg
Mean Pressure :............................................................................................
- Suhu :............................................................................................
- Nadi :............................................................................................
- Pernafasan :............................................................................................
b. KeadaanUmum
- Penampilan :............................................................................................
- Kesadaran
Kuantitatif (GCS) : E = ……
M= ……
V = ……
Jumlah : ……….
Kualitatif ComposmentisApatisDelirium Confulsi
Samnolen Semi coma Coma

c. Kepala
- Struktur Simetris Asimetris Caput succaedenum
- Fontanela Menonjol  Rata Cekung
- Kulit kepalaBersih Kotor hematoma lesi kernikscaseosa
- Nyeri / Pusing ada tidak
- Rambut
Distribusi :............................................................................................
Warna :............................................................................................
- Keluhan lain :............................................................................................

d. Ma ta / Penglihatan
- Ketajaman Jauh…………Dekat………
- Sklera Putih merah icterus
- Pupil ukuran isokor Anisokor
Reflek terhadap cahaya Miosis midriasis
- Konjungtiva merah Muda Pucat merah  Lain-lain.
- Gerak bola mata :............................................................................................
- Refleks kornea :............................................................................................
- Kelopak mata Normal Ptosis Edema
 Lain-lain,jelaskan…………..
- Alat Bantu penglihatan kacamata lensa kontak
- Sekret Ada Tidak

e. Hidung / Penciuman
- Struktur :............................................................................................
- Fungsi :............................................................................................
- Perdarahan :............................................................................................
- sinus/polip :............................................................................................
- Cairan/lendir : ada tidak

f. Rongga mulut
- Mukosa mulut Lembab Kering Sariawan
- Lidah Bersih Kotor Lesi pecah
- pembesaran tonsil ada merah Abses membran putih Tidakada
- nyeri menelan ada tidak
- Gigi Bersih Berlubang+caries
lengkap tidak lengkap
g. Telinga / Pendengaran
- Struktur SimetrisAsimetris
- FungsiBaik
 Test detikarloji……………….
 Test dgn menggesek tangan/rambut
 Test garputala
 Test Swabach
 Test weber
 Test rinne

- Nyeri :............................................................................................
- Serumen :............................................................................................
- Cirantelinga :............................................................................................

h. Leher
- Distensi vena jugolaris :............................................................................................
- pembesaran thyroid ada tidak
- pembesaran kelenjar getah bening ada Tidak
- kaku kuduk  Ada Tidak

i. Pernapasan
- Kualitas nafas  Dalam  Dangkal  Cepat lambat
- Bunyi nafas  Vesicular Rales Ronchi
Wheezing Pleural Friction rub
- Tipe / Pola Teratur Dispnoe Orthopnoe Cheynestokes
biot Kussmaul

- Batuk :............................................................................................
- Sputum :............................................................................................
- Struktur dada Simetris Asimetris
- Bentuk thoraks  Normal  Pigeon chest Funnel chest Barrel chest
- Pemeriksaan Rontgen :............................................................................................
- Penggunaan otot Bantu pernapasan.........................................................................:
 Retraksi supraklavikular  Retraksi sub kostal
 Retraksi interkostal  Retraksi suprasternal
- Penggunaan alat Bantu pernapasan
 O2…………l/mnt Ventilator
j. kardiovaskuler
- Ukuran jantung  normal ICS- 5 Kardiomegali lain-lain,jelaskan……
- Nyeri dada ada  Tidak
- Palpitasi  ada  tidak
- Denyut jantung :............................................................................................
- Bunyi jantung S1/S2 Murmur  Gallop
- Sianosis Ada Tidak
- Jari-jari tabuh/Clubbing finger ada tidak
- CRT ;............................................................................................
- Lain-lain :............................................................................................
k. Abdomen
- Struktur Simetris asimetris
- Nyeri tekan  Ada Tidak ada
- Bising usus : ………..x/Menit
- Benjolan :............................................................................................
- Pembesaran hati ada tidak
- pembesaran limfa ada tidak
- kembung  Ada Tidak
- Mual  ada Tidak
- Muntah
- Frekuensi :............................................................................................
- Jumlah :............................................................................................
- karakteristik .............................................................................................
- Mulas .............................................................................................
- Ascites .............................................................................................
- Keadaan lainnya .............................................................................................

l. Kulit :
- Ptekie/ekimosis YaTidak
- Turgor JelekBaik
- Lesi :............................................................................................
- Kelembaban :............................................................................................
- Diaforesis :............................................................................................
- Sianosis :............................................................................................
- Lain-lain :............................................................................................

m. Eliminasi
- Frekuensi BAK/ 24 jam:............................................................................................
- Jumlah urine : …………cc/24 jam
- Keluhan BAK Nyeri Inkontinensia
Jelaskan .............................................................................................
- Penggunaan kateter Ya Tidak
- Karakteristik urine
Warna jernih keruh Merah
Bau  ammonia Aseton Pesing/Khas
- Frekuensi BAB/24 jam :............................................................................................
- Keluhan BAB Konstipasi Diare Tenesmus
- karakteristik Feses  Cair Berlendir Berdarah ada ampas
Lunak keras  lain-lain, jelaskan …………………
- Colostomi .............................................................................................

n. Muskuloskeletal
- kekuatan otot .............................................................................................
- Tonus otot .............................................................................................
- Fraktur .............................................................................................
- Atropi .............................................................................................
- Edema .............................................................................................
- Persendian
a. Rentang gerak  Terbatas Jelaskan…….. Bebas/aktif  kaku sendi
 b. Kontraktur  Ada  Tidak
c. Tanda-tanda radang  Nyeri edema merah Panas Functiolasea

- tulangbelakang Skoliosis Kyposis Lordosis Takadakelainan

- Aktivitas Mandiri Bantuansebagian Bantuansepenuhnya

o. Neurology
- Fungsi Nervus I .............................................................................................
- Fungsi nervus II .............................................................................................
- fungsi nervus III .............................................................................................
- Fungsi nervus IV .............................................................................................
- Fungsi nervus V .............................................................................................
- Fungsi nervus VI .............................................................................................
- Fungsi nervus VII .............................................................................................
- Fungsi nervus VIII .............................................................................................
- Fungsi nervus IX .............................................................................................
- Fungsi nervus X .............................................................................................
- Fungsi nervus XI .............................................................................................
- Fungsi nervus XII .............................................................................................
- Aktivitas kejang
jenis .............................................................................................
Lama .............................................................................................
- kelumpuhan .............................................................................................
- Reflek patologis
Babinski ya tidak
- Fungsi sensoris
a.Reaksi terhadap nyeri......................................................... Ada  tidak ada
b.Reaksi terhadap suhu ..................................................... ada tidak ada
c.Reaksi thd raba .................................................................ada tidak ada

- Afek
a. Emosi Labilstabil
b. alam perasaan Sedih Gembira Cemas Lain-lain,sebutkan………………
- Orientasi
a. Waktu .............................................................................................
b. Tempat .............................................................................................
8. Orang .............................................................................................

1. Genitalia
Struktur .............................................................................................
Kelainan .............................................................................................
Iritasi ada tidak
Sekret ada tidak
Anus Normal Atresia ani

2. Psikososial
Hubungan dgn keluarga .............................................................................................
Pola interaksi .............................................................................................
Komunikasi .............................................................................................
 Norma dan keyakinan yang dianut...........................................................................................
Tanggapan keluarga ttg penyakit .............................................................................................
13. Diagnosa medis :............................................................................................

14. Hasil Pemeriksaan Penunjang :

- Laboratorium :............................................................................................
urine :............................................................................................
Darah :............................................................................................
Sputum :............................................................................................
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- X-Ray / ECG :............................................................................................
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- Lain-lain :............................................................................................
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15. Program Pengobatan Dokter :............................................................................................

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16. CatatanTambahan :............................................................................................

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17. Ringkasan secara umum tentang pasien :................................................................................

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Mahasiswa yang
melakukanPengkajian

( ……………………….. )
NIM.