I.

IDENTITAS
Inisial Nama : By. T Alamat : Palembang
Tempat/tgl.lahir : 18-11-2020 Agama : Islam
Usia : 1 hari Suku Bangsa : Palembang
Nama Ayah/Ibu : Tn. M Pendidikan ayah : SMA
Pekerjaan Ayah : Buruh Pendidikan ibu : SMA
Pekerjaan Ibu : Ibu Rumah tangga

II. RIWAYAT KEPERAWATAN

a. Keluhan Utama (saat masuk RS)
Ibu klien mengatakan Anaknya belum BAB dan perut anaknya tampak kembung
b. Keluhan utama (saat pengkajian)
Ibu klien mengatakan anaknya belum BAB , dia mengkhawatirkan perut anaknya
yang kembung
c. Riwayat Perjalanan Penyakit
Ibu mengeluhkan anaknya belum BAB , ibu juga mengatakan perutnya kembung
sehingga ibu melaporkan anaknya ke perawat yang bertugas
d. Riwayat Kehamilan dan Kelahiran Anak

Prenatal : ibu mengatakan memeriksaakan kandungannya sekali selama hamil

Internatal : ibu melahirkan di RS dengan usia kandungan 36 minggu, BB bayi 2200

gram dan panjang 45CM

Postnatal : …………………………………….................................................................................................
e. Riwayat Masa Lampau
1.Penyakit waktu kecil :
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2.Pernah dirawat di RS :
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3.Obat-obatan yang digunakan:
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4.Tindakan (operasi) :
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5.Alergi
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 6.Kecelakaan :
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7.Imunisasi :
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f. Riwayat Keluarga
Genogram

Keterangan : : Laki-Laki

: Perempuan
: Menikah
: Anak
: Tinggal Serumah
X : Meninggal
: Klien

g. Riwayat Sosial
Yang mengasuh : ibu dan ayah dibantu
Hubungan dengan anggota keluarga : …………………………….................................……….....
Hubungan dengan teman sebaya : …………………………….................................……
Pembawaan secara umum : …………………………….................................………..
Lingkungan rumah : …………………………….................................………...

IV. KEADAAN KESEHATAN SAAT INI

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V. PENGKAJIAN FISIK (12 DOMAIN NANDA)

1. PROMOSI KESEHATAN (KESADARAN & MANAJEMEN KESEHATAN)
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Masalah keperawatan:
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2. NUTRISI (MAKAN, PENCERNAAN, ABSORPSI, METABOLISME & HIDRASI)
a. Mulut
Trismus ( ), Halitosis ( )
Bibir: lembab( ), pucat( ), sianosis( ), labio/palatoskizis( ), stomatitis( )
Gusi: ( ), plak putih( ), lesi( )
Gigi: Normal( ), Ompong( ), Caries( ), Jumlah gigi:...................
Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
b. Leher
Kaku Kuduk ( ) Simetris( ), Benjolan ( ) Tonsil ( )
Kelenjar Tiroid : normal ( ), pembesaran ( )
Tenggorok : kesulitan menelan ( ), dll..................................................................................................
Kebutuhan Nutrisi dan Cairan
BB sebelum sakit: kg BB sakit: kg
Makanan yang disukai:..........................
Selera makan:...........................
Alat makan yang digunakan:........................
Pola makan( x/ hari):......................
Porsi makan yang dihabiskan:............................
Pola Minum .............................gelas/hari) jenis air minum:.....................................................
c. Abdomen
Inspeksi : Bentuk: simetris( ), tidak simetris( ), kembung( ), asites( ),
Palpasi : massa ( ), nyeri ( )
Kuadran I :
Kuadran II :
Kuadran III :
Kuadran IV :
Auskultasi : bising usus........................x/mnt
Perkusi : Timpani ( ), redup ( )
Data Tambahan :
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Masalah keperawatan:
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3. ELIMINASI & PERTUKARAN (FUNGSI URINARIUS, GASTROINTESTINAL & PERNAPASAN)

Pola Eliminasi
BAK:
Warna:
Konsistensi:
Frekuensi: x/ hari
Urine Output : cc
Penggunaan Kateter:................................................................................................................................
Vesika Urinaria: Membesar .....................Nyeri tekan............................
Gangguan; Anuaria ( ), Oliguria ( ), Retensi Uria ( ), nokturia ( ), Inkontinensia Urin (
), Poliuria ( ), Dysuria ( )
Jelaskan:...............................................................................................................

BAB : warna........................................Frekuensi................................x/hari
Konsisitensi:.................................... lendir ( ), darah ( ), ampas ( )
Konstipasi ( )

Jalan nafas: Sputum ( ), warna sputum ( ) konsisitensi:........................................

Batuk ( ) frekuensi:..............................

Dada
 Bentuk: Simetris ( ), Barrel chest/dada tong( ), pigeon chest/dada burung ( ) benjolan (
), dll………………..

Paru-paru:
Inspeksi: RR………x/ min,
Palpasi: Normal ( ), ekspansi pernafasan( ), taktil fremitus( )
Perkusi: Normal/ Sonor( ), redup/pekak( ), hiper sonor( )
Auskultasi: irama( ), teratur( ),
Suara nafas: vesicular( ), bronkial( ), Amforik ( ), Cog Wheel Breath Sound ( )
metamorphosing breath sound ( )
Suara Tambahan: Ronki ( ), pleural friction( )
Data Tambahan :
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Masalah keperawatan:
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4. AKTIVITAS / ISTIRAHAT (ISTIRAHAT, AKTIVITAS, KESEIMBANGAN ENERGI, RESPON
KARDIOVASKULAR / PULMONAL & PERAWATAN DIRI)
Jantung
Inspeksi: ictus cordis/denyut apeks( ), normal( ) melebar( )
Palpasi: kardiomegali( )
Perkusi: redup( ), pekak( )
Auskultasi: HR...............x/mnt. Aritmia( ),Disritmia( ) , Murmur ( )
Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa saat
tidur,dll):
Kebiasaan Tidur siang:......................................jam/hari
Skala Aktivitas:
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
 Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi/ROM
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung
total

Personal hygine :
Mandi:...................x/hari
Sikat gigi :........................................x/hari
Ganti Pakaian :..................................x/hari
Memotong kuku:...............................x/hari
Data Tambahan :
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Masalah keperawatan:
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5. PERSEPSI / KOGNISI (PERHATIAN, ORIENTASI, SENSASI PERSEPSI, KOGNISI &

KOMUNIKASI)
a. Kesan Umum
Tampak Sakit: ringan ( ), sedang ( ), berat ( ), pucat ( ), sesak ( ), kejang ( )
b. Kepala
Bentuk:........................ Hematoma( ), Luka( )
Fontanel: cekung ( ), Datar ( ), Keras ( ), Lunak ( )
Rambut: warna...............mudah dicabut ( ), ketombe( ), kutu( )
c. Mata
Mata: jernih( ), mengalir, kemerahan( ), sekret( )
Visus: 6/6( ), 6/300( ), 6/ tak terhingga( ),
Pupil: Isokor( ), anisokor( ), miosis( ), midriasis( ),
 reaksi terhadap cahaya: kanan Positif( ), negatif( ), kiri negatif( ) positif( ),
alat bantu: kacamata( ), Softlens( )
Conjungtiva: merah jambu( ), anemis( )
Sklera: Putih( ), Ikterik( )
d. Telinga
Simetri( ), sekret( ), radang( ), Pendengaran: ( ), kurang( ), tuli( )
e. Hidung : Simetris( ), pilek( ), epistaksis( )
f. Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
Data Tambahan :
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Masalah keperawatan:
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6. PERSEPSI DIRI (KONSEP DIRI, HARGA DIRI,& CITRA TUBUH)

Perasaaan klien terhadap penyakit yang didieritanya.............................................................................
Persepsi klien terhadap dirinya.........................................................................................................................
Konsep diri....................................................................................................................................................................
Tingkat kecemasan....................................................................................................................................................
CitraDiri/Bodyimage:..............................................................................................................................................
Data Tambahan :
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Masalah keperawatan:
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7. HUBUNGAN PERAN (PERAN PEMBERI ASUHAN, HUBUNGAN KELUARGA & PERFORMA

PERAN)
Masalah sosial yang penting:
Hubungan orang tua dan bayi:
Orang terdekat yang dapat dihubungi:
Orang tua berespon terhadap penyakit: ya ( ) tidak ( )
Respon:
Orang tua berespon terhadap hospitalisasi: ya ( ) tidak ( )
Data Tambahan
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Masalah keperawatan:
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8. SEKSUALITAS (IDENTITAS, FUNGSI SEKSUALITAS & REPRODUKSI)

Genitalia dan Anus
Laki-laki
Penis: normal/ada ( ), Abnormal…………………,
Scrotum dan testis: normal( ), hernia( ), hidrokel( )
Anus ; normal/ada ( ), atresia ani( )
Perempuan
Vagina: sekret( ), warna( )
Anus: normal/ada ( ), atresia ani( )
Data Tambahan
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Masalah keperawatan:
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9. KOPING / TOLERANSI STRESS (RESPONS PASCATRAUMA, RESPON KOPING & STRES

NEUROBIHAVIOUR)
GCS :.......
E:........................................................................................
V: .......................................................................................
M:.......................................................................................
Reflek Patologis :
Babinsky .............................................................................................................
Kernig ...........................................................................................................
Brudzinsky..................................................................................................
Reflek Fisiologis:
Biceps.................................................................................................................
Triceps...............................................................................................................
Patella........................................................................
Data Tambahan
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Masalah keperawatan:
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10. PRINSIP HIDUP (NILAI, KEYAKINAN & KESELARASAN / KEYAKINAN)

Budaya :
Spritual / Religius :
Harapan :
Psikososial :
 Data Tambahan
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Masalah keperawatan:
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11. KEAMANAN / PERLINDUNGAN (INFEKSI, CEDERA FISIK, KEKERASAN, BAHAYA

LINGKUNGAN, PROSES PERTAHANAN, & TERMOREGULASI)
Tingkat Kesadaran : Composmentis ( ), Apatis ( ), Somnolen ( ),
Sopor (),Soporocoma ( ) Coma ( )
TTV : Suhu.............O C, Nadi........x/min, TD...............mmHg, RR..........x/min
Warna kulit :
Sianosis ( ), I kterus ( ), eritematosus rash ( ), discoid lupus ( ),
oedema ( ),
Bula ( ), Ganggren ( ), nekrotik jaringan ( ), Hiperpigmentasi ( )
Echimosis ( ), Petekie ( )
Turgor Kulit: elastis ( ), tidak elastis ( )
Data Tambahan
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Masalah keperawatan:
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12. KENYAMANAN (FISIK, LINGKUNGAN & SOSIAL)

Nyeri : Ya ( ) Tidak ( )
Jika ya, Pengkajian nyeri :
P (Provokatif/paliatif)
Q( Quality)
R(Regio)
S(Scale)
T(Time)
Data Tambahan
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Masalah keperawatan:
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13. PERTUMBUHAN / PERKEMBANGAN

PEMERIKSAAN TINGKAT PERKEMBANGAN (DDST/KPSP)
Kemandirian dan bergaul : …………….................................………………………..................
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Motorik Halus : …………………………................................…….........................

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Kognitif dan bahasa : ………………………………................................…......................
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Motorik kasar : ……………………………................................………...................
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Data Tambahan
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Masalah keperawatan:
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TERAPI

Terapi Cara Pemberian Dosis Golongan / Jenis Indikasi

PEMERIKSAAN PENUNJANG

Tanggal Pemeriksaan