ASUHAN KEPERAWATAN PADA An.

”R”
DENGAN DIAGNOSA BRONKOPNEUMONIA
DI RS WIRA HUSADA

Nama mahasiswa :
Tanggal praktek :
Tempat praktek :
Sumber data :
Metode pengumpulan data :

A. PENGKAJIAN Tanggal pengkajian :

Waktu pengkajian : pkl. WIB
1. IDENTITAS
a. Pasien
Nama : An. “ R“
TTL :
Usia : 3 tahun bulan hari
Jenis Kelamin : laki-laki
Agama : islam
Suku/ Bangsa : jawa/indonesia
Alamat : jl.babarsari TB. IV
No. RM :
Tgl. Masuk RS : 7 Februari 2021
Diagnosa medis : Bronkopneumonia sinsitra

b. Penanggung Jawab
Nama Ayah : Tn.”X”
Umur : 26 th
Pekerjaan : wiraswasta
Pendidikan : SMA
Nama ibu : Ny. ‘’A’’
Umur : 25 th
Pekerjaan : IRT
Pendidikan : SMA
 Agama : islam
Suku Bangsa : jawa/indonesia
Alamat : jl.babarsari TB.IV

2. RIWAYAT KESEHATAN
a. Riwayat Pasien
1) Keluhan utama
Ibu pasien mengatakan anak R sesak tapi sudah berkurang, batuk berdahak,
demam, nafsu makan menurun
2) Riwayat kesehatan sekarang
Orang tua mengatakan awalnya anaknya sempat tersedak saat makan dirumah
sekitar 2 hari kemudian anak batuk berdahak ±2 hari dan demam kemudian pada
tanggal 7 Februari 2021 orang tua mengatakan anaknya dibawa keklinik lalu
mendapat terapi uap siangnya anak sesak dan langsung dibawa ke IGD RS Wira
Husada
3) Riwayat Penyakit DahulU
ibu mengatakan anak memiliki alergi terhadap debu. Ibu pasien mengatakan
memiliki penyakit asma dan menurun pada Anak R.

3. RIWAYAT KEHAMILAN DAN KELAHIRAN

1) Prenatal
Kehamilan Trimester I :

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Kehamilan Trimester II :

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Kehamilan Trimester III :

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2) Intra natal
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3) Post natal
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4. RIWAYAT MASA LALU

1) Penyakit masa kecil
Ibu pasien megatakan anaknya memiliki riwayat asma dari kecil
2) Riwayat dirawat di Rumah Sakit
Ibu pasien mengatakan demam kemudian pada tanggal 7 Februari 2021 orang tua
mengatakan anaknya dibawa keklinik lalu mendapat terapi uap siangnya anak sesak
dan langsung dibawa ke IGD RS Wira Husada
3) Alergi
ibu mengatakan anaknya memiliki alergi terhadap debu
4) Obat-obatan yang digunakan
 Cefotaxime (IV) 3x300mg
 Certidex (IV) 2x2mg
 Puyer batuk (PO) 3x1
 Paracetamol (IV) 3x100mg
 Nebul ventolin (Inhalasi) /8jam
 IVFD D5 1/2 10 tpm

5) Tindakan (operasi)
Ibu pasien mengatakan An.R belum pernah melakukan tindakan operasi
 6) Imunisasi
 Hepatitis B : lengkap
 BCG : lengkap
 DPT : lengkap
 Polio : lengkap
 Campak : lengkap

5. RIWAYAT KELUARGA
a. Genogram

Keterangan :
: laki-laki : garis perkawinan
: perempuan : garis keturunan

: klien ------- : garis tinggal satu rumah

b. Riwayat Kesehatan Keluarga
ibu pasiem mengatakan memiliki riwayat asma yang menurun pada An.R

6. RIWAYAT SOSIAL
a. Yang mengasuh
Yang mengasuh klien adalah ibu dan ayah
 b. Hubungan dengan anggota keluarga
ibu pasien mengatakan hubungan An.R dengan keluarga baik dibuktikan dengan An.R
sering bermain bersama keluarga.
c. Hubungan dengan teman sebaya
d. ibu pasien mengatakan hubungan An.R dengan teman sebaya baik dibuktikan
dengan An.R sering bermain bersama teman-temanya tapi semenjak sakit An.R
tidak pernah bermain lagi dengan teman-temannya.
e. Pembawaan secara umum
Ibu pasien mengatakan bahwa An.R tipe anak yang ceria,aktif dan suka bermain
f. Lingkungan rumah
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7. KEBUTUHAN DASAR
a. Nutrisi
Sebelum sakit
1) Pola makan
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2) Porsi makan
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3) Alat makan
Alat makan yang digunakan : ....................................................................................
 Selama sakit
1) Selera makan
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2) Pola makan
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3) Porsi makan
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b. Tidur dan istirahat
Sebelum sakit
1) Pola tidur
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2) Kebiasaan sebelum tidur
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3) Tidur siang
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Selama sakit
1) Pola tidur
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2) Kebiasaan sebelum tidur
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3) Tidur siang
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c. Personal higiene
Sebelum sakit
1) Mandi
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2) Menggosok gigi
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Selama sakit
1) Kebersihan diri
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2) Kebersihan mulut dan gigi
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d. Aktivitas bermain
Sebelum sakit
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Selama sakit
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e. Eliminasi
Sebelum sakit
 BAB : ...................................................................................................................
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 BAK

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Selama sakit
 BAB : ................................................................................................................
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  BAK : ................................................................................................................
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8. PEMERIKSAAN FISIK
a. Keadaan umum :
b. Kesadaran :
c. Nilai GCS : E:
V:
M:
Total nilai GCS :
d. Antropometri
Tinggi badan : cm Lingkar Kepala : cm
Berat badan : Kg Lingkar Dada : cm
Lingkar Lengan Atas : cm Lingkar Perut : cm
Status gizi :
Intepretasi Status Gizi :

e. Tanda-tanda vital :
TD : / mmHg
Nadi : kali/ mnt,
R : kali/menit
0
Suhu : C
Pengkajian Nyeri :

f. Kepala :
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g. Mata :
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h. Hidung :
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i. Mulut :
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j. Telinga :
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k. Leher :
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l. Tengkuk :
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m. Dada :

Jantung
Inspeksi
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Palpasi
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Perkusi
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Auskultasi
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Paru - paru
Inspeksi
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Palpasi
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Perkusi
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Auskultasi
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Abdomen
Inspeksi
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Auskultasi
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Palpasi
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Perkusi
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n. Urogenitalia
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o. Ekstremitas
Ekstremitas atas :
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Ekstremitas bawah :
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Kulit
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9. ASPEK MENTAL-INTELEKTUAL
a. Intelektual Orang Tua
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b. Support system keluarga
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10. DETEKSI TUMBUH KEMBANG (dilakukan jika pasien balita)
A. Motor kasar
Kegiatan Umur Waktu normal menurut teori
Mengepal Bulan 1 bulan
Tengkurap Bulan 8 bulan
Merangkak Bulan 10 bulan
Berdiri Bulan 18 bulan
Berjalan tidak jatuh Bulan 18 bulan
Berlari Bulan 24 bulan
Naik tangga Bulan 36 bulan

B. Motor halus
Kegiatan Umur Waktu normal menurut teori
Melihat sekitar Bulan 1 bulan
Memegang benda Bulan 4 bulan
Memindahkan benda Bulan 12 bulan
Menggambar garis Bulan 18 bulan
Menggambar lingkaran Bulan 24 bulan
Menggambar orang Bulan 48 bulan

C. Bicara
Kegiatan Umur Waktu normal menurut teori
Mengoceh Bulan 1 bulan
Tertawa Bulan 4 bulan
Berteriak Bulan 7 bulan
Ucap 1 kata Bulan 10 bulan
Ucap 2 kata Bulan 12 bulan
Berkata tanpa arti Bulan 18 bulan
 Bicara lancar Bulan 48 bulan

D. Sosial
Kegiatan Umur Waktu normal menurut teori
Melihat orang Bulan 1 bulan
Mengenal orang Bulan 4 bulan
Bermain Bulan 7 bulan
BAB/BAK sendiri Bulan 18 bulan

E. Pemeriksaan Refleks

Kesimpulan :
11. PEMERIKSAAN PENUNJANG

Hasil pemeriksaan laboratorium darah rutin tgl . pkl.......... WIB

Jenis Hasil Satuan Nilai normal Interpretasi
WBC 103/uL 4.8 – 10,8
Neu% % 43.0 – 65.0
Ly% % 20.5 – 45.5
Mo% % 5.5 – 11.7
Eo% % 0.9 – 2.9
Ba% % 0.2 – 1.0
Neu # % 2,2 – 4,8
Ly# % 1,3 – 2,9
Mo# % 0,3 – 0,8
Eo# % 0,0 – 0,2
Ba # % 0,0 – 0,1
RBC 106/uL 4.7 – 6.1
HGB g/dl 14 – 18
HCT % 42 – 52
MCV FL 80 – 94
MCH FL 27 – 31
MCHC g/dl 32 – 36
RDW FL 11.5 – 15.5
PLT 103/ul 130 – 400
MPV FL 7.4 – 10.4
PCT % 0,00 – 0.99
PDW ratio 0.0 – 99.9

B. Radiologi
12. TERAPI MEDIS YANG DIDAPAT

Terapi yang didapat klien saat pengkajian tgl.

Nama Obat Dosis 1 Kali Dosis Per Rute Fungsi Obat

Pemberian Hari
Cefotaxime 300 mg 3x300 mg IV
Certidex 2 mg 2x2 mg IV
Puyer batuk 1 mg 3x1 mg PO
Paracetamol 100 mg 3x100 mg IV
Nebu ventolin 8 jam 8 jam
IVFD D5 1/2 10 tpm IV
ANALISA DATA
N
Data Penyebab Masalah
o
DS:
 Ibu pasien
mengatakan anak
R sesak tapi
sudah berkurang,
batuk berdahak,
demam, nafsu
makan menurun
 ibu mengatakan
anak memiliki
alergi terhadap
debu. Ibu pasien
mengatakan
memiliki penyakit
asma dan menurun
Ketidakefektifan Sekrsi yang
1. pada Anak R. pola nafas tertahan

DO:

 TTV
 S : 37,8 °C
 N :
97x/menit
 RR : 35X/Menit
INTERVENSI KEPERAWATAN
Rencana
Diagnosa
Tanggal/Jam
Keperawatan NOC NIC
Ketidakefektifan Pola Setelah dilakukan tindakan keperawatan NIC : Manajemen Asma
Nafas b.d Sekeresi selama 3x24 jam diharapkan ketidakefektifan 1. Identifikasi pemicu yang
yang tertahan pola nafas dapat teratasi dengan kriteria diketahui dan reaksi yang
hasil : biasanya terjadi
NOC : Status Pernafasan 2. Ajarkan tehnik relaksasi nafas
dalam
N Indikator A T
Keterangan : 3. Ajarkan tehnik yang tepat untuk
O
1. Frekuensi pernafasan 2 4 1 : Deviasi berat dari kisaran normal pengobatan dan alat yang tepat
2. Kemampuan 2 4 2 : Deviasi yang cukup berat dari (misalnya inhaler,nebulizer,peak
mengeluarkan secret kisaran normal flow meter)
3 : Deviasi sedang dari kisaran normal
4 : Deviasi ringan dari kisaran normal
5 : Tidak ada deviasi dari kisaran normal
IMPLEMENTASI KEPERAWATAN

Diagnosa Tgl/Ja Evaluasi TT

Implementasi
Keperawatan m D
Proses Hasil
Ketidakefektifa 12-02- Pukul: Pukul: Pukul:
n pola nafas b.d 2021 - Mengidentifikasi DS: S:
Sekresi yang pemicu yang diketahui - Ibu pasien mengatakan - Ibu pasien mengatakan
tertahan dan reaksi yang anaknya memiliki sesak pada anaknya
biasanya terjadi riwayat asma sudah berkurang
 - Ibu pasien mengatakan
anaknya mengalami
batuk berdahak
sehingga kadang
menyebabkan sesak
nafas.
DO:
- Pasien tampak batuk
O:
- Anak tampak mempraktikkan
apa yang diajarkan oleh
perawat
- TTV
- S : 37,8 °C
- N : 97x/menit
- RR : 25X/Menit

Pukul; Pukul:
- Mengajarkan tehnik DS: -
relaksasi nafas dalam DO:
A : Tujuan tercapai
- Anak tampak
Indikator A T C
mempraktikkan apa 1. Frekuensi 2 4 4
yang diajarkan oleh pernafasan
perawat
Pukul: 2. Kemampuann 2 4 4
- Ajarkan tehnik yang tepat Pukul: mengeluarkan
untuk pengobatan dan alat DS: - sekret
yang tepat (misalnya DO:
inhaler,nebulizer,peak flow - Memberika terapi P : Hentikan intervensi
meter) obat:
 Cefotaxime (IV)
 3x300mg,
 Certidex (IV)
2x2mg,
 Puyer batuk (PO)
3x1,
 Paracetamol (IV)
3x100mg,
 Nebu ventolin
(Inhalasi) /8jam,
 IVFD D5 1/2 10
tpm
- TTV
- S : 37,8 °C
- N : 97x/menit
- RR : 35X/Menit