ASUHAN KEPERAWATAN PADA ANAKDENGAN KASUS .DI RUANG ISMAIL II (BANGSAL ANAK)RS ROEMANI

1. PENGKAJIAN1. Data DemografiKlien/Pasien0. Tanggal pengkajian : ......................................................................................................0. Tanggal masuk: ......................................................................................................0. Ruangan: ......................................................................................................0. Identitas Nama: ...................................................................................................... Tanggal lahir/umur: ...................................................................................................... Jenis kelamin: ...................................................................................................... Agama: ...................................................................................................... Suku : ...................................................................................................... Diagnosa medis: ...................................................................................................... Penanggung jawab: ......................................................................................................Orang Tua/ Penanggung Jawab1. Nama : .......................................................................1. Hubungan dengan klien: ...........................................................................1. Suku: ...........................................................................1. Agama: .......................................................................1. Alamat: ...................................................................................1. No. telepon: ...........................................................................................

1. Riwayat KlienRiwayat penyakit klien sebelumnya: ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Riwayat kehamilan (ANC, masalah kesehatan selama kehamilan, dll): ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................1. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit persalinan, dll): .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................1. Riwayat imunisasi (lengkapi)Hepatitis B IBCGHepatitis B IIHepatitis B IIIPolio IPolio IIPolio IIIPolio IVDPT IDPT IIDPT IIICampakLAINNYA,sebutkan.......................................................1. Riwayat alergi :...........................................................................................................................................................1. Riwayat pemakaian obat-obatan : ...................................................................................................................................................1. Riwayat tumbuh kembang (Sejak lahir hingga sekarang): Motorik halus: ......................................................................................................................................................................................................................................................................................................................Motorik kasar: ......................................................................................................................................................................................................................................................................................................................Bahasa:......................................................................................................................................................................................................................................................................................................................Personal sosial: ......................................................................................................................................................................................................................................................................................................................Reflek primitif (Neonatus)......................................................................................................................................................................................................................................................................................................................

1. Riwayat Kesehatan Keluarga0. Riwayat penyakit dalam keluarga:.........................................................................................................................................................................................................................................................................0. Genogram

Keterangan gambar :: laki-laki : klien: perempuan: : : : : : meninggal: tinggal dalam satu rumah

1. Riwayat Penyakit sekarang0. Penampilan umumKeadaan umum ......................................................................................................................................................................................................................................................................3. Pemeriksaaan Tanda-Tanda Vital0. Pernapasan: ...........................0. Suhu: ...........................0. Nadi: ........................... 0. Tekanan Darah: ........................... 0. Saturasi oksigen: ...........................3. Penggunaan alat bantu napas (Oksigen, CPAP, dll)............................................................................................................................................................................................................................................................................................................

1. Nutrisi dan cairan:1. Lingkar Lengan atas : .................cm1. Panjang badan/tinggi badan: ................cm1. Berat badan: .................kg1. Lingkar kepala : ................ cm1. Lingkar dada: ................... cm1. Lingkar perut: ....................cm1. Status nutrisi (z-score atau WHO, CDC):.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. Kebutuhan kalori :..................................................................................................................................................................................................................................................................................................................................................................................................................................1. Jenis makanan: ............................................................................................................................Makanan yang disukai:............................................................................................................................................................................................................................................................................................................Alergi makanan :............................................................................................................................................................................................................................................................................................................1. Kesulitan saat makan :............................................................................................................................................................................................................................................................................................................1. Kebiasaan khusus saat makan : ...........................................................................................................................................................................................................................................................................................................1. Keluhan (mual, muntah, kembung, anoreksia, dsb ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

1. Kebutuhan cairan 24 jam:............................................1. Balance cairan (hitung jumlah dan jenis cairan masuk dan keluar):1. Nilai Balance Cairana. IWL

NoIntakeOutput

JenisJumlahJenisJumlah

1.Minum BAK

2.MakanMuntah

3.InfusIWL

Feses (1x/ hari)

JumlahJumlah

Balance Cairan = Intake Output

= =

1. Diuresis : ............................................................................................................................................................................................................................................................................................................1. Rute cairan masuk (oral, parenteral, enteral, dsb)............................................................................................................................................................................................................................................................................................................1. Jenis cairan (ASI/susu formula/infus/air putih, dsb):..................................................................................................................................................................................................................................................................................................................................................................................................................................................................1. Keluhan: ............................................................................................................................................................................................................................................................................................................

1. Istirahat tidur1. Lama waktu tidur (24 jam) : . jam1. Kualitas tidur: ..................................................................................................1. Tidur siang (ya/tidak) : ...................................................................................................1. Kebiasaan sebelum tidur: ...................................................................................................

1. Pengkajian nyeri (sesuai usia, lampirkan alat ukur):................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ......................................................................................................................................................................................................................................................................................................................

1. Pemeriksaan Fisik (Head to toe)1. KepalaInspeksi.............................................................................................................................................................................................................................................................................................................................................................................................

Palpasi.............................................................................................................................................................................................................................................................................................................................................................................................

1. MataInspeksi.........................................................................................................................................................................................................................................................................................................................................................

Palpasi.........................................................................................................................................................................................................................................................................................................................................................

1. HidungInspeksi.........................................................................................................................................................................................................................................................................................................................................................

Palpasi.........................................................................................................................................................................................................................................................................................................................................................

1. TelingaInspeksi.........................................................................................................................................................................................................................................................................................................................................................

Palpasi.........................................................................................................................................................................................................................................................................................................................................................

1. MulutInspeksi........................................................................................................................................................................................................................................................................................................................................................

Palpasi.........................................................................................................................................................................................................................................................................................................................................................

1. LeherInspeksi.........................................................................................................................................................................................................................................................................................................................................................

Palpasi.........................................................................................................................................................................................................................................................................................................................................................

1. Dada1. Paru-paruParu-paruKeterangan

Inspeksi..............................................................................................................................................................................................................................................................................................................................

Palpasi..............................................................................................................................................................................................................................................................................................................................

Perkusi..............................................................................................................................................................................................................................................................................................................................

Auskultasi..............................................................................................................................................................................................................................................................................................................................

1. JantungJantungKeterangan

Inspeksi..............................................................................................................................................................................................................................................................................................................................

Palpasi..............................................................................................................................................................................................................................................................................................................................

Perkusi..............................................................................................................................................................................................................................................................................................................................

Auskultasi..............................................................................................................................................................................................................................................................................................................................

1. AbdomenAbdomenKeterangan

Inspeksi..............................................................................................................................................................................................................................................................................................................................

Auskultasi..............................................................................................................................................................................................................................................................................................................................

Palpasi..............................................................................................................................................................................................................................................................................................................................

Perkusi..............................................................................................................................................................................................................................................................................................................................

1. KulitInspeksi..............................................................................................................................................................................................................................................................................................................................

Palpasi..............................................................................................................................................................................................................................................................................................................................

1. GenitaliaInspeksi..............................................................................................................................................................................................................................................................................................................................

Palpasi..............................................................................................................................................................................................................................................................................................................................

1. Ekstremitas..........................................................................................................................................................................................................................................................................................................................................................................................................................................Kekuatan otot :

1. Psikososial anak dan keluarga0. Respon hospitalisasi (rewel, tenang): ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................0. Kecemasan (anak dan orang tua) ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................0. Koping klien/keluarga dalam menghadapi masalah ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................0. Pengetahuan orang tua tentang penyakit anak............................................................................................................................................................................................................................................................................................................0. Keterlibatan orang tua dalam perawatan anak ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................0. Konsep diri Gambaran tubuh .................................................................................................................................................................................................................................................................................................................................................................................................................................................................Ideal diri..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Harga diri..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Peran..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Identitas diri..................................................................................................................................................................................................................................................................................................................................................................................................................................................................0. Spiritual (kebiasaan ibadah, keyakinan, nilai, budaya)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................0. Adakah terapi lain selain medis yang dilakukan..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

1. Pemeriksaan penunjang (laboratorium, radiologi)

Nama testHasilFlag UnitNilai rujukan

Nama testHasilFlag UnitNilai rujukan

1. Terapi: .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

1. ANALISA DATANODATAPROBLEMETIOLOGI

1. TABEL DIAGNOSA KEPERAWATANNOTGL/JAMDITEMUKANDXKEPTTDTGL/JAMTERATASITTD

1. RENCANA KEPERAWATANNOTGL/JAMDX KEPINTERVENSI

TUJUANTINDAKANTTD

1. IMPLEMENTASINODX.KEPTGL /JAMIMPLEMENTASIRESPONTTD

1. EVALUASI (perkembangan setiap hari dalam bentuk SOAPNOTGL/JAMDX KEPEVALUASITTD