Format Pengkajian Asuhan Keperawatan pada Bayi

I. IDENTITAS BAYI IDENTITAS ORANG TUA

Nama : ........................... Nama Ayah : ...........................
Tgl Lahir : ........................... Nama Ibu : ...........................
Jenis Kelamin : ........................... Pekerjaaan Ayah/Ibu : ...........................
Tgl MRS : ........................... Pendidikan Ayah/Ibu : ...........................
Alamat : ........................... Alamat : ...........................
Diagnosa Medis : ........................... Suku Bangsa : ...........................
Sumber Informasi : ........................... Agama : ...........................
No. RM : ...........................

II. RIWAYAT KEPERAWATAN

1. Riwayat Keperawatan Sekarang
a. Keluhan utama : .....................................................................................
...............................................................................................................................
...............................................................................................................................
b. Riwayat penyakit saat ini : .....................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

2. Riwayat Keperawatan Sebelumnya

a. Riwayat kesehatan yang lalu
 Penyakit yang pernah diderita : ..........................................................................
 Operasi : ..........................................................................
 Alergi
- Obat : ...............................................................................................
..
- Makanan : .................................................................................................
- Debu : ...............................................................................................
..
- Lainnya : .................................................................................................
b. Riwayat Persalinan
 Prenatal : .................................................................................................
.............................................................................................................................
.............................................................................................................................
 Natal : .................................................................................................
.............................................................................................................................
.............................................................................................................................
 Postnatal : .................................................................................................
.............................................................................................................................
.............................................................................................................................
c. Imunisasi
BCG : ................... Polio : ......................... DPT : ...............
Campak : .................. Hepatitis : .........................
3. Riwayat Kesehatan Keluarga
a. Penyakit yang pernah diderita oleh anggota keluarga :
.....................................................................................................................................
.....................................................................................................................................
b. Lingkungan rumah dan komunitas:
.....................................................................................................................................
 .....................................................................................................................................
c. Perilaku yang mempengaruhi
kesehatan: .....................................................................................................................................
.....................................................................................................................................
d. Persepsi keluarga terhadap penyakit anak:
.....................................................................................................................................
.....................................................................................................................................
4. Nutrisi
a. Nafsu makan :
.....................................................................................................................................
.....................................................................................................................................
b. Pola makan :
....................................................................................................................................
....................................................................................................................................
c. Minum : .......................................................................................................................
............
...................................................................................................................................
d. Pantangan makanan :
....................................................................................................................................
....................................................................................................................................
e. Menu makanan :
....................................................................................................................................
....................................................................................................................................
5. Pertumbuhan
a. BB: ........ kg, TB: ......... cm LK: ......... cm LD: ........... cm
LILA: .......... cm
Status gizi (BB/TB) : ..............................................................................................
6. Perkembangan
Untuk usia 0 bulan s.d 72 bulan dengan menggunakan KPSP
a. Motorik kasar
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
................................................................................................................................

b. Motorik halus
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
c. Sosialisasi dan kemandirian/personal sosial
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
................................................................................................................................
d. Bahasa
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
................................................................................................................................
 Kesimpulan : ..............................................................................................................
7. Genogram (3 generasi)

II. PENGKAJIAN FISIK

Kesadaran : ............................................................................................................
Suhu: .........°C Nadi: ...........x/menit Tensi: ................mmHg
RR: ............x/menit
a. Kepala
Rambut : warna ...................... penyebaran ............................
Kebersihan ..............................................................................
b. Mata
Bentuk : ..................................................................................
Sklera : ..................................................................................
Konjungtiva : ..................................................................................
Penglihatan : ..................................................................................
c. Hidung
Bentuk : ..................................................................................
Septum nasi : .................................................................................
Sekret : .................................................................................
PCH : .................................................................................
Penciuman : ................................................................................
d. Mulut
 Bibir
Bentuk : ...............................................................................
Mukosa bibir : ...............................................................................
Kelainan bawaan : ...............................................................................
Refleks rooting : ...............................................................................
 Lidah
Bentuk : ................................................................................
Kebersihan : ................................................................................
Refleks ekstrusi : ................................................................................
 Gusi
Warna : ...............................................................................
Lain-lain : ...............................................................................
 Gigi
Sudah tumbuh/belum : .........................................................................
Caries gigi : .........................................................................
e. Telinga
Bentuk : ..............................................................................
Kebersihan : ..............................................................................
Tragus pain : ..............................................................................
Refleks startle : ..............................................................................
f. Leher
Bentuk : .............................................................................
Bendungan vena jugularis : .......................................................................
Pembesaran kelenjar tiroid : .......................................................................
g. Thorax/dada
Inspeksi
Bentuk : ............................................................................
 Kelainan bentuk dada : ............................................................................
Tarikan intercostae : ............................................................................
Palpasi
Fraktur tulang costae : ............................................................................
Vokal vremitus : ............................................................................
Perkusi
Suara paru : ............................................................................
Auskultasi
Suara nafas tambahan : ...........................................................................
h. Abdomen/perut
Inspeksi
Bentuk : ...........................................................................
Asiteas : ...........................................................................
Auskultasi
Bising usus : .............. x/menit
Perkusi
Suara : .........................................................................
Palpasi
Kuadran I : .........................................................................
Kuadran II : .........................................................................
Kuadran III : .........................................................................
Kuadran IV : .........................................................................
i. Punggung
Bentuk : ........................................................................
Kelainan bentuk punggung : ...................................................................
j. Genetalia
Kebersihan : ........................................................................
Kelainan bawaan : ........................................................................
k. Anus
Kebersihan : ..................................................................
Kelainan bawaan : ..................................................................
l. Ekstremitas
Kelainan jumlah jari : .................................................................
Akral : .................................................................
CRT : .................................................................
III. PEMERIKSAAN DIAGNOSTIK
.....................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
IV. THERAPI / TINDAKAN
.....................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
Lampiran 2

Format Pengkajian Asuhan Keperawatan Neonatus

I. DATA ADMINISTRASI
Tanggal MRS :
Diantar oleh : keluarga Perawat / Bidan
Dikirim oleh : OK R. Bersalin Lainnya
Diagnosa medis:
No RM :
II. DATA IBU
Nama:.................................................................. Umur...........................................
Agama................................................................. Suku Bangsa.................................
Status Perkawinan ................................................Lama Perkawinan.....................
Gravida....................................Para......................Diagnosa Obstetri...........................
Alamat................................................................................................................
...........................................................................................................................
Nama Penanggung Jawab.......................................................................................
Lain-lain..............................................................................................................

III.KELUHAN UTAMA
IV. RIWAYAT PENYAKIT SEKARANG
............................................................................................................................
…………………………………………………………………………………………..
V. RIWAYAT PENYAKIT MASA LALU
 Prenatal:

 Natal:

 Postnatal:

VI. NUTRISI / ASI / PASI

 Menyusui....................ASI / PASI:

 Makanan tambahan:

 Kebiasaan makan:

VII. PENGKAJIAN FISIK

BB.................gr TB.......................cm
1. Kepala
a. Rambut
 Warna : Penyebaran:
 Lingkar Kepala :
 Ubun-Ubun :
 Sutura :
 Lain-lain :
b. Mata
 Conjungtiva :
 Sklera :
 Bulu mata :
 Alis :
 Kornea :
 Pupil :
 Lain-lain :
c. Telinga
 Aurikula :
 Lubang telinga :
 Pendengaran :
 Lain-lain :
d. Hidung
 Bentuk :
 Lubang hidung :
 Lain-lain :
e. Mulut
 Bibir :
 Lidah :
 Palatum :
 Mukosa :
 Lain-lain :
f. Faring
 Tonsil :
 Lain-lain :
2. Leher
a Vena jugularis :
b Struma :
c Lain-lain :
3. Dada
a Bentuk dada :
b Pola nafas :
c Jenis pernafasan :
d Bunyi nafas :
e Perkusi thorax :
f Alat bantu :
g Bunyi jantung :
h Putting susu :
4. Abdomen
a Bentuk :
b Tali pusat :
c Distensi abdomen :
d Lain-lain :
5. Genetalia / Anus
a Jenis kelamin :
 b Hernia :
c BAB :
d BAK :
e Lain-lain :
6. Ekstremitas atas / bawah
a Normal / lengkap :
b Akral :
c Lain-lain :
7. Tulang, Syaraf dan Kulit
a Tulang belakang :
b Reflek :
c Kulit :
d Warna :
e Lain-lain :

VIII. PEMERIKSAAN PENUNJANG

IX. TERAPI / TINDAKAN

X. DAFTAR PRIORITAS MASALAH

1.
2.
3.
Lampiran 3

Format Pengkajian Asuhan Keperawatan Anak

I. IDENTITAS ANAK IDENTITAS ORANG TUA

Nama : ........................... Nama Ayah : ...........................
Tgl Lahir : ........................... Nama Ibu : ...........................
Jenis Kelamin : ........................... Pekerjaaan Ayah/Ibu : ...........................
Tgl MRS : ........................... Pendidikan Ayah/Ibu : ...........................
Alamat : ........................... Alamat : ...........................
Diagnosa Medis : ........................... Suku Bangsa : ...........................
Sumber Informasi : ........................... Agama : ...........................
No. RM : ...........................

II. RIWAYAT KEPERAWATAN

1. Riwayat Keperawatan Sekarang
a. Keluhan utama : .....................................................................................
...............................................................................................................................
...............................................................................................................................
b. Riwayat penyakit saat ini : .....................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
2. Riwayat Keperawatan Sebelumnya
a. Riwayat kesehatan yang lalu
 Penyakit yang pernah diderita : ..........................................................................
 Operasi : ..........................................................................
 Alergi
- Obat : ...............................................................................................
..
- Makanan : .................................................................................................
- Debu : ...............................................................................................
..
- Lainnya : .................................................................................................
b. Riwayat Persalinan
 Prenatal : .................................................................................................
.............................................................................................................................
.............................................................................................................................
 Natal : .................................................................................................
.............................................................................................................................
.............................................................................................................................
 Postnatal : .................................................................................................
.............................................................................................................................
.............................................................................................................................
c. Imunisasi
BCG : ................... Polio : .........................
DPT : ...................... Campak : .................. Hepatitis : …………
3. Riwayat Kesehatan Keluarga
a. Penyakit yang pernah diderita oleh anggota keluarga : ..................................................
.....................................................................................................................................
 b. Lingkungan rumah dan
komunitas: .....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
c. Perilaku yang mempengaruhi
kesehatan: .....................................................................................................................................
....................................................................................................................................
d. Persepsi keluarga terhadap penyakit
anak: .....................................................................................................................................
.....................................................................................................................................
4. Nutrisi
a. Nafsu makan :
.....................................................................................................................................
.....................................................................................................................................
b. Pola makan :
....................................................................................................................................
.................................................................................................................................... c. Minum
:
…................................................................................................................................
....................................................................................................................................
c. Pantangan makanan :
....................................................................................................................................
....................................................................................................................................
d. Menu makanan :
....................................................................................................................................
....................................................................................................................................
Pertumbuhan
BB: ........ kg, TB: ......... cm LK: ......... cm LD: ........... cm
LILA: .......... cm
Status gizi (BB/TB) : ..............................................................................................
5. Perkembangan
Untuk usia 0 bulan s.d 72 bulan menggunakan KPSP
a. Motorik kasar
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
................................................................................................................................
b. Motorik halus
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
................................................................................................................................
c. Sosialisasi dan kemandirian/personal sosial
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
................................................................................................................................
d. Bahasa
...............................................................................................................................
 ...............................................................................................................................
...............................................................................................................................
................................................................................................................................
Kesimpulan : ..............................................................................................................
6. Genogram (3 generasi)

III. PENGKAJIAN FISIK

Kesadaran : ............................................................................................................
Suhu: .........°C Nadi: ...........x/menit Tensi: ................mmHg
RR: ............x/menit
a. Kepala
Rambut : warna ...................... penyebaran ............................
Kebersihan ..............................................................................
b. Mata
Bentu : ..................................................................................
Sklera : ..................................................................................
Konjungtiva : ..................................................................................
Penglihatan : ..................................................................................
c. Hidung
Bentuk : ..................................................................................
Septum nasi : .................................................................................
Sekret : .................................................................................
PCH : .................................................................................
Penciuman : ................................................................................
d. Mulut
 Bibir
Bentuk : ...............................................................................
Mukosa bibir : ...............................................................................
Kelainan bawaan : ...............................................................................
Refleks rooting : ...............................................................................
 Lidah
Bentuk : ................................................................................
Kebersihan : ................................................................................
Refleks ekstrusi : ................................................................................
 Gusi
Warna : ...............................................................................
Lain-lain : ...............................................................................
 Gigi
Sudah tumbuh/belum : .........................................................................
Caries gigi : .........................................................................
e. Telinga
Bentuk : ..............................................................................
Kebersihan : ..............................................................................
Tragus pain : ..............................................................................
Refleks startle : ..............................................................................
f. Leher
Bentuk : .............................................................................
Bendungan vena jugularis : .......................................................................
Pembesaran kelenjar tiroid : .......................................................................
 g. Thorax/dada
Inspeksi
Bentuk : ............................................................................
Kelainan bentuk dada : ............................................................................
Tarikan intercostae : ............................................................................
Palpasi
Fraktur tulang costae : ............................................................................
Vokal vremitus : ............................................................................
Perkusi
Suara paru : ............................................................................
Auskultasi
Suara nafas tambahan : ...........................................................................
h. Abdomen/perut
Inspeksi
Bentuk : ...........................................................................
Asiteas : ...........................................................................
Auskultasi
Bising usus : .............. x/menit
Perkusi
Suara : .........................................................................
Palpasi
Kuadran I : .........................................................................
Kuadran II : .........................................................................
Kuadran III : .........................................................................
Kuadran IV : .........................................................................
i. Punggung
Bentuk : ........................................................................
Kelainan bentuk punggung : ...................................................................
j. Genetalia
Kebersihan : ........................................................................
Kelainan bawaan : ........................................................................
k. Anus
Kebersihan : ..................................................................
Kelainan bawaan : ..................................................................
l. Ekstremitas
Kelainan jumlah jari : .................................................................
Akral : .................................................................
CRT : .................................................................
IV. DAMPAK HOSPITALISASI
a. Pada anak : ...........................................................................
...........................................................................................................
...........................................................................................................
...........................................................................................................
b. Pada orang tua :
...........................................................................................................
...........................................................................................................
...........................................................................................................

V. 11 POLA FUNGSI KESEHATAN: (di rumah dan selama dirawat di RS)

No Pola Fungsi Kesehatan Di Rumah Di Rumah
Sakit

1 Pola persepsi :
 Persepsi terhadap kesehatan / sakit

Pengobatan / penatalaksanaan keperawatan

Penggunaan tembakau, alkohol dan obat-obatan dll

Pola aktivitas sehari-hari / latihan :

Makan, mandi, berpakaian, toileting, tingkat mobilitas di tempat
tidur, berpindah, berjalan, berbelanja, memasak, kekuatan otot,
kemampuan ROM.

Tingkat kemampuan klien dalam beraktivitas, yaitu:

2 0 = berarti mandiri

1 = menggunakan alat bantu

2 = dibantu orang lain

3 = dibantu orang dan peralatan

4 = ketergantungan atau tidak mampu.

Pola nutrisi :

Diet khusus

Nafsu makan

Jumlah makan / minum / cairan yang masuk

3
Mual / muntah

Stomatitis

Kesulitan menelan

Penggunaan gigi palsu

4 Pola eliminasi :

a. Defekasi / BAB
Kebiasaan

Jumlah

Konsistensi

Warna

Konstipasi

Diare

b. BAK
Kebiasaan
 Jumlah

Konsistensi

Warna

Gangguan / kelainan: (disuria, hematuri, retensi,

inkontinensia, nocturia)

Pemasangan kateter

Pola tidur / istirahat :

Jumlah jam tidur (pagi, siang, malam)

5 Gangguan selama tidur

Terbangun dini

Insomnia / mimpi buruk

Kognitif- perceptual :

Orientasi (waktu, tempat, orang)

6
Tidak ada respons

Kemampuan berkomunikasi

Toleransi-koping stress :

7 Mekanisme koping

Tingkat toleransi stress yang pernah dialami

Persepsi diri / konsep diri :

Masalah yang dialami (kecemasan, ketakutan, penilaian

terhadap diri):
8  Peran
 Ideal diri
 Harga diri
 Gambaran diri
Identitas diri

Pola sexual-reproduksi :

Periode menstruasi terakhir

9
Masalah Pap Smear

Pemeriksaan payudara

10 Pola hubungan & peran :

 Hubungan klien dengan keluarga

Kemampuan bekerja

Gangguan terhadap peran yang dilakukan

11 Pola nilai & keyakinan :

Kegiatan keagamaan

VI. PEMERIKSAAN DIAGNOSTIK

.....................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
VII.THERAPI / TINDAKAN
.....................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
Lampiran 4

Format pengkajian resiko jatuh menurut humpty dumpty

Parameter Kriteria Nilai Skor

< 3 tahun 4

3 – 7 tahun 3
Usia
7 – 13 tahun 2

≥ 13 tahun 1

Jenis kelamin Laki-laki 2

Perempuan 1

Diagnosis Diagnosis neurologi 4

Perubahan oksigenasi (diagnosis 3

respiratorik, dehidrasi, anemia,
anoreksia, pusing, sinkop)

Gangguan perilaku/psikiatri 2

Diagnosis lainnya 1

Gangguan kognitif Tidak menyadari keterbatasan 3

dirinya

Lupa akan adanya keterbatasan 2

Orientasi baik terhadap diri 1

sendiri

Faktor lingkungan Riwayat jatuh/bayi diletakkan di 4

tempat tidur dewasa

Pasien menggunakan alat 3

bantu/bayi diletakkan dalam
tempat tidur bayi/perabot rumah

Pasien diletakkan di tempat idur 2

Area di luar rumah sakit 1

Respon terhadap: Dalam 24 jam 3

1. Pembedahan/sedasi/anastesi Dalam 48 jam 2

 2. Penggunaan medikamentosa > 48 jam atau tidak menjalani 1
pembedahan/sedasi/anastesi

Penggunaan multipel: sedatif, 3

obat hipnosis, barbiturat,
fenotiazin, antidepresan,
pencahar, diuretik, narkose

Penggunaan salah satu obat di 2

atas

Penggunaan mediaksi 1
lainnya/tidak ada medikasi

Skor asesmen risiko jatuh: (skor minimum 7, skor maksimum 23)

a. Skor 7 – 11 : risiko rendah
b. Skor ≥ 12 : risiko tinggi
Lampiran 5
Format pengkajian nyeri

Kategori Skor

Tidak ada ekspresi tertentu atau senyuman 0

Wajah Menyeringai sekali-kali atau mengerutkan dahi, muram ogah- 1

FACE ogahan

Dagu gemetar dan rahang diketap berulang 2

Posisi normal atau santai 0

Ekstremitas
Gelisah, resah, tegang 1
LEG
Menendang atau menarik kaki 2

Rebahan dengan tenang, posisi normal, bergerak dengan mudah 0

Gerakan
Menggeliat, maju, mundur, tegang 1
Activity
Menekuk/posisi tubuh meringkuk, kaku atau menyentak 2

Tidak ada tangisan (terjaga atau tertidur ) 0

Tangisan Mengerang/merengek, gerutuan sekali-kali 1

Cry
Menangis tersedu-sedu, menjerit terisak-isak, menggerutu berulang- 2
ulang

Senang, santai 0
Kemampuan
Dapat ditenangkan dengan sentuhan, pelukan atau berbicara, dapat 1
Ditenangkan
dialihkan
Consolabilit
y Sulit/tidak dapat ditenangkan dengan pelukan, sentuhan atau 2
distraksi

Lampiran 6
Format Laporan Pendahuluan
1. Definisi kasus (Masalah utama)
2. WOC (Etiologi, faktor risiko, tanda dan gejala, masalah keperawatan)
3. Pemeriksaan penunjang
4. Penatalaksanaan
5. Pengkajian data fokus
6. Diagnosis keperawatan
7. Rencana tindakan (Kriteria hasil)
8. Referensi