ASUHAN KEPERAWATAN PADA ANAK

(RUANG PERAWATAN ANAK)

I. PENGKAJIAN
A. Data Demografi
1. Klien/Pasien
a. Tanggal pengkajian : ...................................
b. Tanggal masuk : ...................................
c. Ruangan : ..................................
d. Identitas
Nama : ...................................
Tanggal lahir/umur: ................................
Jenis kelamin : ...................................
Agama : ...................................
Suku : ...................................
Diagnosa medis : ...................................
Penanggung jawab: ...............................

2. Orang Tua/ Penanggung Jawab

a. Nama : ...
b. Hubungan dengan klien :
c. Suku : ...
d. Agama :
e. Alamat :
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f. No. telepon : .........

B. Riwayat Klien
1. Keluhan utama saat ini :
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Riwayat penyakit klien sebelum masuk rumah sakit :
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2. Riwayat sakit sebelumnya :
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3. Riwayat kehamilan (ANC, masalah kesehatan selama kehamilan, dll) :

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4. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit
persalinan, dll):
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 5. Riwayat imunisasi (lengkapi)
Hepatitis B I BCG
Hepatitis B II Hepatitis B III
Polio I Polio II
Polio III Polio IV
DPT I DPT II
DPT III Campak
LAINNYA,sebutkan.......................................
6. Riwayat alergi : .................................

7. Riwayat pemakaian obat-obatan :

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8. Riwayat tumbuh kembang (Sejak lahir hingga sekarang):

Motorik halus:

Motorik kasar:
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Bahasa :
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Personal sosial
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C. Riwayat Kesehatan Keluarga

1. Riwayat penyakit dalam keluarga:
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2. Genogram
 Keterangan gambar :
: laki-laki : klien

: perempuan : meninggal

: tinggal dalam satu rumah

D. Riwayat Penyakit sekarang

1. Penampilan umum
a. Keadaan umum (kondisi klien secara umum):
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b. Pemeriksaaan Tanda-Tanda Vital

1) Pernapasan : ....................
2) Suhu : .....................
3) Nadi : .....................
4) Tekanan Darah : ...................
5) Saturasi oksigen : ..................
c. Penggunaan alat bantu napas (Oksigen, dll)
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2. Nutrisi dan cairan:

a. Lingkar Lengan atas :..................cm
b. Panjang badan/tinggi badan : ................cm
c. Berat badan : ..................kg
d. Lingkar kepala : ..................cm
e. Lingkar dada : ..................cm
f. Lingkar perut : ...................cm
g. Status nutrisi (z-score atau WHO, CDC) :
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h. Kebutuhan Kalori :
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i. Jenis makanan: ..........................................................

Makanan yang disukai :
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Alergi makanan :
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j. Kesulitan saat makan :
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k. Kebiasaan khusus saat makan:
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 l. Keluhan (mual, muntah, kembung, anoreksia, dsb...):
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m. Kebutuhan cairan 24 jam :

a. Balance cairan (hitung jumlah dan jenis cairan masuk dan keluar):
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b. Diuresis :
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c. Rute cairan masuk (oral, parenteral, enteral, dsb)
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d. Jenis cairan (ASI/susu formula/infus/air putih, dsb):

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e. Keluhan :
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3. Istirahat tidur
a. Lama waktu tidur (24 jam) : jam
b. Kualitas tidur :..
c. Tidur siang (ya/tidak)
d. Kebiasaan sebelum tidur : ..........................................

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

5. Pemeriksaan Fisik (Head to toe)

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6. Psikososial anak dan keluarga
a. Respon hospitalisasi (rewel, tenang)
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b. Kecemasan (anak dan orang tua)

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c. Koping klien/keluarga dalam menghadapi masalah

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d. Pengetahuan orang tua tentang penyakit anak

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e. Keterlibatan orang tua dalam perawatan anak

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f. Konsep diri
- Gambaran Tubuh
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- Ideal Diri
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- Harga Diri
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- Peran
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- Identitas Diri
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g. Spiritual (kebiasaan ibadah, keyakinan, nilai, budaya)

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 h. Adakah terapi lain selain medis yang dilakukan
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7. Pemeriksaan penunjang (laboratorium, radiologi)

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 8. Terapi
Nama Obat Dosis Cara Pemberian Indikasi Kontraindikasi Efek Samping
9. ANALISA DATA
NO DATA PROBLEM ETIOLOGI
10. PROBLEM LIST
NO TGL/JAM DITEMUKAN DX KEP TTD TGL/JAM TERATASI TTD

11. RENCANA KEPERAWATAN

NO TGL DX KEP INTERVENSI
/JAM
TUJUAN TINDAKAN TTD
12. IMPLEMENTASI

TGL
NO DX KEP IMPLEMENTASI RESPON TTD
/JAM
13. EVALUASI

NO TGL/JAM DX KEP EVALUASI TTD