ASUHAN KEPERAWATAN PADA An.

I DENGAN FEBRIS DI RUANG ANGGREK

RUMAH SAKIT UMUM DAERAH dr. SOERATNO GEMOLONG

Nama Pengkaji :
Tanggal dan jam pengkajian :
Tanggal Masuk :
Tempat Praktik :

1. PENGKAJIAN
A. IDENTITAS DATA
Nama (inisial) :
TTL :
Usia :
Pendidikan :
Alamat (asal kota) :
Agama :
Nama Ayah (inisial) :
Nama Ibu (inisial) :
Pekerjaan Ayah :
Pekerjaan Ibu :
Pendidikan Ayah :
Pendidikan Ibu :
Alamat (asal kota) :
Agama :
Suku / Bangsa :

B. KELUHAN UTAMA
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C. RIWAYAT PENYAKIT SEKARANG
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D. RIWAYAT MASA LAMPAU

1. Prenatal ( keluhan sat hamil, ANC dmn, nutrisi, fultrm/pre/postmatur, kesehatan saat
hamil, Obat yang di minum )
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2. Natal ( tindakan persalinan, obat-obatan, tempat persalinan )

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3. Postnatal ( kondisi kesehatan, APSGAR Scor, BBL, PBL )
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No. 1, 2, 3 ditanyakan pada pasien yang masih kecil !

4. Penyakit waktu kecil (diagnosa, Gejala, penanganan)
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5. Pernah dirawat dirumah sakit (penyakit yang diderita, lama perawatan)

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6. Obat-obatan yang digunakan (pernah/sedang digunakan, Jenis, dosis, alasan pemakaian)

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7. Alergi ( pernah mengalami alergi makanan, sejak kapan, debu, dll )

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8. Kecelakaan ( jenis kecelakan, akibat, tindakan )

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 9. Imunisasi ( di rinci apa saja yang pernah didapat )
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E. RIWAYAT KELUARGA ( GENOGRAM )

F. RIWAYAT SOSIAL
1. Yang mengasuh dan alasannya
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2. Pembawaan secara umum (periang pemalu, pendiam, kebiasaan lain : menghisap jari)
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 3. Lingkungan rumah ( berhubungan dengan kebersihan rumah, ventilasi )
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G. KEADAAN KESEHATAN SAAT INI

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H. PENGKAJIAN POLA GORDON

1. Persepsi kesehatan dan pola management kesehatan
Status kesehatan anak sejak lahir, pemeriksaan kesehatan secara rutin, imunisasi, apakah
orang tua merokok, keluarga punya simpanan obat ?
Imunisasi 0 bln 2 bln 3 bln 4 bln 7 bln 9 bln
BCG
POLIO I
POLIO II
POLIO III
POLIO IV
DPT I
DPT II
DPT III
HB I
HB II
 HB III
CAMPAK

2. Nutrisi – Pola metabolisme

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3. Pola Eliminasi
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4. Aktifitas – Pola latihan

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5. Pola Istirahat – Tidur

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6. Pola Kognitif – Persepsi
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7. Persepsi Diri – Pola Konsep Diri

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8. Pola Peran – Hubungan

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9. Seksualitas
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10. Koping – Pola Toleransi Stress

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11. Nilai – Pola Keyakinan

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I. PEMERIKSAAN FISIK
KU :
TTV :
S :
N :
RR :
TD :
Nyeri : (jika ada)

TB/BB :
Lingkar kepala :
Mata :

Hidung :

Mulut :

Telinga :

Tengkuk :

Dada :

Jantung :

Paru-paru :

Perut :

Punggung :

Genetalia :

Ekstremitas :

Kulit :
J. PEMERIKSAAN PERKEMBANGAN
Untuk anak usia 0 – 6 tahun menggunakan format DDST
Tanggal Sektor
Lahir Yang Aktivitas yang Dilakukan Hasil Keterangan
Umur Dinilai
Personal P/F/NO/R A/N/C/D
Sosial

Motorik P/F/NO/R A/N/C/D

Halus
 Bahasa P/F/NO/R A/N/C/D

Motorik P/F/NO/R A/N/C/D

Kasar

JUMLAH

KESIM NORMAL/ADVANCE/SUSPECT
PULAN
 KET :
P : Pass / lewat A : Advenced
F : Fail/Gagal N : Normal
NO : No Oportunity C : Caution
R : Refuse/Menolak D : Delay

Untuk anak usia diatas 6 tahun

1. Berat badan lahir, 5 bulan, 1 tahun dan saat ini
2. Pertumbuhan gigi : usia saat gigi tumbuh, jumlah, masalah dengan pertumbuhan gigi
3. Usia menegakkan kepala, duduk, berjalan, kata-kata pertama
4. Perkembangan sekolah, lancar ? Masalah apa ?
5. Interaksi dengan orang dewasa
6. Partisipasi dengan kegiatan organisasi

K. DATA PENUNJANG
Tanggal Diit Laboratorium Foto Lain-lain
Terapi Obat & IV fluid

Cara
No Tanggal Jenis Obat/ IV Fluid Dosis Indikasi & Dx. Medis
Pemberian
 2. ANALISIS DATA

Hari, Data pendukung Masalah Etiologi Tanda dan

Tanggal (Data Subjektif & Objektif) (Problem) Gejala
3. PRIORITAS DIAGNOSIS KEPERAWATAN
1.
2.
3.

4. RENCANA ASUHAN KEPERAWATAN

Tanggal Perencanaan
No No DX
Jam Tujuan & KH Intervensi
5. IMPLEMENTASI

Tanggal No Tindakan Keperawatan Respon pasien terhadap tindakan TTD/

Waktu DX Nama
Tanggal No Tindakan Keperawatan Respon pasien terhadap tindakan TTD/
Waktu DX Nama
6. EVALUASI

Tanggal No Diagnosa Keperawatan Evaluasi TTD/

Waktu DX (SOAP) Nama