ASUHAN KEPERAWATAN ANAK

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

NIM : …………………………………………………………………………………...
Tempat Praktek : …………………………………………………………………………………...
Tgl Pengkajian : ………………………………………………Jam : …………………………...

I. Biodata
A. Identitas Klien
1. Nama/Nama panggilan : ……………………………………………………………………
2. Tempat tgl lahir/usia : ……………………………………………………………………
3. Jenis kelamin : ……………………………………………………………………
4. A g a m a : ……………………………………………………………………
5. Pendidikan : ……………………………………………………………………
6. Alamat : ……………………………………………………………………
7. Tgl masuk RS : ...................................... (jam ............)
9. Diagnosa medik : ……………………………………………………………………
B. Identitas Orang tua
1. Ayah
a. N a m a : ……………………………………………………………………
b. U s i a : ……………………………………………………………………
c. Pendidikan : ……………………………………………………………………
d. Pekerjaan/sumber penghasilan : ……………………………………………………………
e. A g a m a : ……………………………………………………………………
f. Alamat : ……………………………………………………………………
2. Ibu
a. N a m a : ……………………………………………………………………
b. U s i a : ……………………………………………………………………
c. Pendidikan : ……………………………………………………………………
d. Pekerjaan/Sumber penghasilan: ……………………………………………………………
e. Agama : ……………………………………………………………………
f. Alamat : ……………………………………………………………………
C. Identitas Saudara Kandung
No NAMA USIA HUBUNGAN STATUS KESEHATAN
II. Keluhan Utama
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III. Riwayat Kesehatan Saat Ini
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IV. Riwayat Kesehatan Lalu
1. Prenatal care (khusus untuk anak usia 0 – 5 tahun)
a. Keluhan selama hamil : ………………………………………………………………...
b. Tempat ANC : ………………………………………………………………...
c. Usia kehamilan : preterm/ aterm/ post term
d. Riwayat Obat2an : ………………………………………………………………...
2. Natal (khusus untuk anak usia 0 – 5 tahun)
a. Tempat melahirkan : ………………………………………………………………...
b. Jenis persalinan : ………………………………………………………………...
c. Penolong persalinan : ………………………………………………………………...
d. Komplikasi persalinan : ………………………………………………………………...
3. Post natal (khusus untuk anak usia 0 – 5 tahun)
a. Kondisi kesehatan bayi : ………………………………………………………………...
b. APGAR Skor : ………………………………………………………………...
c. BB Lahir : …………………………, PB Lahir: …………….…………...
4. Penyakit yang pernah diderita :
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5. Pernah dirawat di RS : ya/ tidak
Riwayat Operasi : ……………………………………………………………………………
 Reaksi Hospitalisasi : ……………………………………………………………………………
6. Riwayat Obat2an yang pernah dikonsumsi :
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7. Riwayat Alergi :
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V. Riwayat Keluarga
1. Penyakit yang pernah/ sedang diderita keluarga :
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2. Anak tinggal bersama : ……………………………………………………………………………
3. Pengasuh anak : ……………………………………………………………………………
4. Lingkungan rumah :
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5. Genogram (3 generasi) :

VI. Riwayat Immunisasi (imunisasi lengkap)

No Jenis imunisasi Waktu pemberian Frekuensi Reaksi setelah pemberian
1. BCG
2. DPT (I,II,III)
3. Polio (I,II,III,IV)
4. Campak
5. Hepatitis
 No Jenis imunisasi Waktu pemberian Frekuensi Reaksi setelah pemberian
Lainnya :
a. ………………
6.
b. ………………
dst

VII. Riwayat Pertumbuhan

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VIII. Riwayat Perkembangan (Gunakan Format Denver II dan Lampirkan)
1. Motorik Kasar
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2. Motorik Halus
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3. Sosial
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4. Bahasa
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IX. Riwayat Sosial

 1. Hubungan dengan anggota keluarga :
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2. Hubungan dengan teman sebaya :
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X. Pengkajian Pola Kesehatan Gordon
1. Persepsi Kesehatan dan Manajemen Kesehatan
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2. Pola Nutrisi
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3. Pola Eliminasi
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4. Pola Aktivitas dan Latihan
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5. Pola Istirahat Tidur
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6. Pola Kognitif-Persepsi
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 7. Pola Persepsi Diri-Konsep Diri
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8. Seksualitas
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9. Pola Koping-Toleransi Stres
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10. Pola Peran-Hubungan
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11. Pola Nilai-Keyakinan
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XI. Pemeriksaan Fisik

1. Keadaan umum : ....................................................................................................................
2. Kesadaran : ....................................................................................................................
3. Tanda – tanda vital :
a. Tekanan darah : ..................................... mmHg
b. Denyut nadi : ..................................... x / menit
c. Suhu : ..................................... o C
d. Pernapasan : ..................................... x/ menit
4. Berat Badan : ....................................................................................................................
5. TB/ PB : ....................................................................................................................
6. LK : ....................................................................................................................
7. LLA : ....................................................................................................................
8. Kepala
Inspeksi
Keadaan rambut & Hygiene kepala : ..............................................................................
a. Warna rambut : ..............................................................................
b. Penyebaran : ..............................................................................
 c. Mudah rontok : ..............................................................................
d. Kebersihan rambut : ..............................................................................

Palpasi
Benjolan : ada / tidak ada : ..............................................................................
Nyeri tekan : ada / tidak ada : ..............................................................................
Tekstur rambut : kasar/halus : ..............................................................................

9. Muka
Inspeksi
a. Simetris / tidak : ........................................................................................................
b. Bentuk wajah : ........................................................................................................
c. Gerakan abnormal : ........................................................................................................
d. Ekspresi wajah : ........................................................................................................

Palpasi
Nyeri tekan / tidak : ........................................................................................................
Data lain : ........................................................................................................

10. Mata
Inspeksi
a. Pelpebra : Edema / tidak
Radang / tidak
b. Sclera : Icterus / tidak
c. Konjungtiva : Radang / tidak
Anemis / tidak
d. Pupil : - Isokor / anisokor
- Myosis / midriasis
- Refleks pupil terhadap cahaya : ..................................................
e. Posisi mata :
Simetris / tidak : ..................................................................................................
f. Gerakan bola mata : ..................................................................................................
g. Penutupan kelopak mata : ..................................................................................................
h. Keadaan bulu mata : ..................................................................................................
i. Keadaan visus : ..................................................................................................
j. Penglihatan : - Kabur / tidak
- Diplopia / tidak

Palpasi
Tekanan bola mata : ..................................................................................................
Data lain : ..................................................................................................

11. Hidung & Sinus

Inspeksi
a. Posisi hidung : ..................................................................................................
b. Bentuk hidung : ..................................................................................................
c. Keadaan septum : ..................................................................................................
d. Sekret / cairan : ..................................................................................................
Data lain : ..................................................................................................
12. Telinga
Inspeksi
a. Posisi telinga : ..................................................................................................
b. Ukuran / bentuk telinga : ..................................................................................................
c. Aurikel : ..................................................................................................
d. Lubang telinga : Bersih / serumen / nanah
e. Pemakaian alat bantu : ..................................................................................................

Palpasi
a. Nyeri tekan : ada/ tidak
b. Benjolan : ada/ tidak

Pemeriksaan vestibuler : ..................................................................................................

Data lain : ..................................................................................................

13. Mulut
Inspeksi
a. Gigi
- Keadaan gigi : ..................................................................................................
- Karang gigi / karies : ..................................................................................................
- Pemakaian gigi palsu : ..................................................................................................
b. Gusi
Merah / radang / tidak : ..................................................................................................
c. Lidah
Kotor / tidak : ..................................................................................................
d. Bibir
- Cianosis / pucat / tidak : ............................................................................................
- Basah / kering / pecah : ............................................................................................
- Mulut berbau / tidak : ............................................................................................
- Kemampuan bicara : ............................................................................................
Data lain : ............................................................................................

14. Tenggorokan
a. Warna mukosa : ..................................................................................................
b. Nyeri tekan : ..................................................................................................
c. Nyeri menelan : ..................................................................................................

15. Leher
Inspeksi
Kelenjar thyroid : Membesar / tidak

Palpasi
a. Kelenjar thyroid : Teraba / tidak
b. Kaku kuduk / tidak : ..................................................................................................
c. Kelenjar limfe : Membesar atau tidak
Data lain : ..................................................................................................

16. Thorax dan pernapasan

 Inspeksi
a. Bentuk dada : ............................................................................
b. Irama pernafasan : ............................................................................
c. Pengembangan di waktu bernapas : ............................................................................
d. Tipe pernapasan : ............................................................................
Data lain : ............................................................................

Palpasi
a. Vokal fremitus : ............................................................................
b. Massa / nyeri : ............................................................................

Auskultasi
a. Suara nafas : Vesikuler / Bronchial / Bronchovesikuler
b. Suara tambahan : Ronchi / Wheezing / Rales

Perkusi
Redup / pekak / hypersonor / tympani
Data lain : ............................................................................

17. Jantung
Palpasi
Ictus cordis : ............................................................................
Perkusi
Pembesaran jantung : ............................................................................

Auskultasi
a. BJ I : ............................................................................
b. BJ II : ............................................................................
c. BJ III : ............................................................................
d. Bunyi jantung tambahan : ............................................................................
Data lain : ............................................................................

18. Abdomen
Inspeksi
a. Membuncit : ............................................................................
b. Ada luka / tidak : ............................................................................

Palpasi
a. Hepar : ............................................................................
b. Lien : ............................................................................
c. Nyeri tekan : ............................................................................

Auskultasi
Peristaltik : ............................................................................

Perkusi
a. Tympani : ............................................................................
b. Redup : ............................................................................
Data lain : ............................................................................
 19. Genitalia dan Anus : ............................................................................

20. Ekstremitas
Ekstremitas atas
a. Motorik
- Pergerakan kanan / kiri : ............................................................................
- Pergerakan abnormal : ............................................................................
- Kekuatan otot kanan / kiri : ............................................................................
- Tonus otot kanan / kiri : ............................................................................
- Koordinasi gerak : ............................................................................
b. Refleks
- Biceps kanan / kiri : ............................................................................
- Triceps kanan / kiri : ............................................................................
c. Sensori
- Nyeri : ............................................................................
- Rangsang suhu : ............................................................................
- Rasa raba : ............................................................................

Ekstremitas bawah
a. Motorik
- Gaya berjalan : ............................................................................
- Kekuatan kanan / kiri : ............................................................................
- Tonus otot kanan / kiri : ............................................................................
b. Refleks
- KPR kanan / kiri : ............................................................................
- APR kanan / kiri : ............................................................................
- Babinsky kanan / kiri : ............................................................................
c. Sensori
- Nyeri : ............................................................................
- Rangsang suhu : ............................................................................
- Rasa raba : ............................................................................
Data lain : ............................................................................

21. Status Neurologi.

Tanda – tanda perangsangan selaput otak
a. Kaku kuduk : ............................................................................
b. Kernig Sign : ............................................................................
c. Refleks Brudzinski : ............................................................................
d. Refleks Lasegu : ............................................................................
Data lain : ............................................................................

XII. Test Diagnostik

= Laboratorium
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 = Foto Rotgen, CT Scan, MRI, USG, EEG, ECG
XIII. Terapi saat ini (ditulis dengan rinci)
 ANALISA DATA

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. RM : ..............................................

No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)

 DIAGNOSA KEPERAWATAN

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. RM : ..............................................

Daftar diagnosa keperawatan :

1. ……………………………………………………………………………………………….
2. ……………………………………………………………………………………………….
3. ……………………………………………………………………………………………….
4. ……………………………………………………………………………………………….
5. ……………………………………………………………………………………………….
6. Dst.
 RENCANA KEPERAWATAN

No. Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi Rasional

 TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

Waktu Waktu Catatan Perkembangan

No. Tindakan TT TT
Tgl/jam Tgl/jam (SOAP)