PRODI D3 KEPERAWATAN

UNIVERSITAS JEMBER

FORMAT ASUHAN KEPERAWATAN PADA BAYI/ANAK

Nama Mahasiswa : .........................................................

NIM : .........................................................

Tanggal Praktek : .........................................................

Tanggal Pengkajian : .........................................................

1. IDENTITAS PASIEN
Nama Pasien : ............................................... No. Reg : .................................
Jenis Kelamin : ............................................... Tgl Masuk : .................................
Umur : ............................................... Ruang : .................................
Agama : ...............................................
Bangsa/Suku : ...............................................
Bahasa yang Dipakai : ...............................................
Status Anak : ...............................................
Anak Ke Berapa : ...............................................
Nama Orang Tua : ...............................................
Umur : ...............................................
Agama : ...............................................
Bangsa / Suku : ...............................................
Pendidikan : ...............................................
Pekerjaan : ...............................................
Alamat Rumah : ...............................................

2. INFORMASI MEDIK
Diagnosa Medik : .......................................................................................
Waktu / Pemeriksaan Sebelum MRS : .......................................................................................
Obat Terakhir yang Didapat : .......................................................................................
Alergi Obat : .......................................................................................
Dikirim Oleh : .......................................................................................

3. RIWAYAT KEHAMILAN DAN KELAHIRAN

a. Prenatal : ................................................................................................................
b. Natal : ................................................................................................................
c. Postnatal : ................................................................................................................
4. RIWAYAT TUMBUH KEMBANG
a. Keadaan Waktu Lahir : .......................................................................................
b. Keadaan Mental/Emosi Anak : .......................................................................................
c. Pemeriksaan Tumbuh Kembang
 Motorik Kasar : .......................................................................................
 Motorik Halus : .......................................................................................
 Bahasa : .......................................................................................
 Adaptasi : .......................................................................................

5. RIWAYAT PENYAKIT
a. Keluhan Utama :
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b. Riwayat Penyakit Sekarang :

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c. Riwayat Penyakit Masa Lalu :

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d. Riwayat Penyakit Keluarga :

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e. Riwayat Imunisasi
Imunisasi yang Didapat :
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6. POLA KEBIASAAN PEMELIHARAAN DAN KESEHATAN
a. Pola Makan dan Minum
Makan :
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Minum :
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Jenis Makan/Minum :
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Pantangan :
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Perubahan Pola Makan Selama Sakit :
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b. Pola Istirahat Tidur

Lama Tidur : ...............................................................................................................
Kesulitan Selama Tidur :
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Suasana yang Mempermudah Tidur :
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Suasana yang Mempermudah Terbangun :
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Perubahan Pola Istirahat Tidur Selama Sakit :
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c. Pola Aktivitas
Aktivitas yang dilakukan Sehari-hari :
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Olahraga : ............................................................................
Perubahan Pola Aktivitas Selama Sakit :
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 d. Pola Eliminasi
BAB : ........................ x/hari
Konsistensi : ...............................................................................................................
Warna : ...............................................................................................................
BAK : ........................ x/hari
Warna : ...............................................................................................................
Gangguan BAB : ...............................................................................................................
Gangguan BAK : ...............................................................................................................
Perubahan BAB & BAK Selama Sakit :
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e. Pola Kebersihan Diri

Mandi : ........................ x/hari
Gosok Gigi : ........................ x/hari
Potong Kuku : ........................ x/hari
Ganti Pakaian : ........................ x/hari
Perubahan Pola Kebersihan Diri Selama Sakit :
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7. PENGKAJIAN FISIK
a. Keadaan Umum :
BB : ..........Kg TB : ..........cm LLA : .........cm Lingkar Kepala : ............cm

b. Tanda – Tanda Vital :

Tekanan Darah : ......................mmHg Nadi : .............x/menit
RR : ...........x/menit Suhu : .............°C

c. Kepala
Bentuk :
Ubun – ubun :
( ) Sudah Menutup ( ) Benjolan Abnormal
( ) Belum Menutup ( ) Cephal Haematom
( ) Cekung ( ) Hidrocephalus
( ) Cembung ( ) Mikrocephalus
( ) Cepat Succedanum ( ) Luka Pada ..................................................

d. Mata / Penglihatan
Simetris / Tidak : .....................................................................................................................
Konjungtiva : .....................................................................................................................
Sklera : .....................................................................................................................
Kornea : .....................................................................................................................
 Pupil dan Reflek Cahaya : .........................................................................................................
Visus : ........................................................................................................
T.I.O : ........................................................................................................
Keluhan pada Mata : ........................................................................................................

e. Telinga / Pendengaran
Simetris / Tidak : ........................................................................................................
Serumen : .......................................................................................................
Keadaan Lubang Telinga : .......................................................................................................
Benjolan : .......................................................................................................
Keluhan pada Telinga : .......................................................................................................

f. Hidung / Penciuman
Simetris / Tidak : .......................................................................................................
Benjolan : .......................................................................................................
Perdarahan : .......................................................................................................
Penyumbatan : .......................................................................................................
Lain – lain : .......................................................................................................
Keluhan pada Hidung : .......................................................................................................

g. Mulut
Keadaan Bibir : .......................................................................................................
Keadaan Lidah : .......................................................................................................
Keadaan Gusi : .......................................................................................................
Keadaan T Ponsil : .......................................................................................................
Keadaan Palatum : .......................................................................................................
Keadaan Gigi : .......................................................................................................
Mulai Tumbuh Gigi : .......................................................................................................
Jumlah Gigi : .......................................................................................................
Gangguan Menelan : .......................................................................................................
Keluhan pada Mulut / Gigi / Lidah / Bibir : ..............................................................................

h. Leher
Bentuk : .............................................................................................
Gerakan : .............................................................................................
Benjolan : .............................................................................................
Tekanan Vena Jugularis : .............................................................................................
Kaku Kuduk : .............................................................................................
Pembesaran Kelenjar Limfe : .............................................................................................
Pembesaran Kelenjar Tyroid : .............................................................................................
Bekas Luka : .............................................................................................
Keluhan pada Daerah Luka : .............................................................................................
i. Dada
Kesimetrisan : .................................................................................
Pernafasan : .................................................................................
Pembesaran Buah Dada Abnormal : .................................................................................
Irama Nafas : .................................................................................
Keadaan Puting Susu : .................................................................................
Nyeri Tekan : .................................................................................
Sesak Nafas : .................................................................................
Mulai Membesar Umur : .................................................................................
Nyeri Waktu Nafas : .................................................................................
Suara Nafas Tambahan : .................................................................................
Sputum : .................................................................................
Batuk Darah : .................................................................................
Warna : .................................................................................
Jumlah : .................................................................................

j. Abdomen / Pencernaan :
Tali Pusat Sudah Lepas / Belum : .................................................................................
Keadaan Tali Pusat : .................................................................................
Kebersihan Tali Pusat : .................................................................................
Pembesaran : .................................................................................
Kembung : .................................................................................
Ascites : .................................................................................
Benjolan : ....................................... Pada Kuadran : ..................................
Nyeri Tekan : ............... ....................... Pada Kuadran : ..................................
Pembesaran Hepar : .................................................................................
Pembesaran Vesika Urinaria : .................................................................................
Keluhan Lain pada Daerah Abdomen : .................................................................................

k. Anus Rektum
Varises / Hemoroid : .................................................................................
Benjolan : .................................................................................
Luka : .................................................................................
Inkontinensia Alvi : .................................................................................
Keluhan Lain pada Daerah Anus : .................................................................................

l. Alat Kelamin / Sistem Reproduksi :

Benjolan Pada Vulva : .................................................................................
Benjolan Abnormal pada Skrotum : .................................................................................
Perdarahan : .................................................................................
Kelainan Pada Penis : .................................................................................
Gangguan Kencing : .................................................................................
Kelainan pada Alat Kelamin Luar
Menarche
Menstruasi : ................
Luka
Gangguan pada Menstruasi
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Siklus : ............. Lamanya : ................ Banyaknya : ................
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m. Extremitas / Anggota Badan :

Kesimetrisan Otot : .................................................................................
Pemeriksaan Oedema : .................................................................................
Kekuatan Otot : .................................................................................
Keluhan Lain pada Lengan Dan Kaki : ................................................................................

n. Kulit / Otot / Persendian :

Kulit
- Warna : .......................................... Pada Bagian : ...................................
- Luka : .......................................... Pada Bagian : ...................................
- Hematom : .......................................... Pada Bagian : ...................................
- Kemerahan : .......................................... Pada Bagian : ...................................
- Turgor : .......................................... Pada Bagian : ...................................

Otot
Tonus Otot : ......... ................................................................................................................

Persendian :
- Gangguan Pergerakan :
- Nyeri Tekan : ........................................ Pada Sendi : ...........................
- Pembengkakan : ....................................... Pada Sendi : ...........................
- Keluhan Lain : .............................................................................................

Pemeriksaan Neurologi

- Reflek Babinski : .........................................................................................................

- Reflek Moro : .........................................................................................................
- Reflek Sucking : .........................................................................................................
- Graps Refleks : .........................................................................................................

Tingkat Kesadaran

Kejang : .........................................................................................................

Tremor : .........................................................................................................

Anastesi : .........................................................................................................
 Parastesi : .............................................................................................

Hipostesi : .............................................................................................

Keluhan Lain Pada Neurologi : .............................................................................................

8. DATA PSIKOSOSIOSPIRITUAL
Perilaku Non Verbal : .............................................................................................
Keadaan Emosi : .............................................................................................
Pola Hubungan dengan Orang Lain : .............................................................................................
Orang yang Sangat Dekat Dirinya : .............................................................................................
Ketaatan dalam Beribadah : .............................................................................................
Kegiatan Keagamaan yang Dapat Mengurangi Stress : ..................................................................

9. INFORMASI PENUNJANG
Pemeriksaan Laboratorium :
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Pemeriksaan EKG :
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Pemeriksaan Rontgen :
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Pemeriksaan Lain – lain :

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 Terapi Sekarang Yang Diberikan :
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10. REAKSI PADA SAAT PENGKAJIAN

Anamnese Dilakukan Terhadap :
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Reaksi Pasien Pada Waktu Pengkajian :
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Reaksi Keluarga Pada Waktu Pengkajian :

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