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LAPORAN ASUHAN KEPERAWATAN ANAK
I. PENGKAJIAN1. Identitas
a. Identitas PasienNama : .........................................................................................................Umur : .........................................................................................................Agama : .........................................................................................................Jenis Kelamin : .........................................................................................................Status : .........................................................................................................Pendidikan :..........................................................................................................Pekerjaan : .........................................................................................................Suku Bangsa :..........................................................................................................Alamat : .........................................................................................................Tanggal Masuk : .........................................................................................................Tanggal Pengkajian : .........................................................................................................No. Register : .........................................................................................................Diagnosa Medis : .........................................................................................................
2. Identitas Oran Tuaa. Ayah N a m a : ……………………………………………………………………………….. U s i a : ……………………………………………………………………………….. Pendidikan : ……………………………………………………………………………….. Pekerjaan : ……………………………………………………………………………….. A g a m a : ……………………………………………………………………………….. Alamat : ………………………………………………………………………………..
b. Ibu N a m a : ……………………………………………………………………………….. U s i a : ……………………………………………………………………………….. Pendidikan : ……………………………………………………………………………….. Pekerjaan : ……………………………………………………………………………….. A g a m a : ……………………………………………………………………………….. Alamat : ………………………………………………………………………………..
c. Identitas Saudara Kandung
No Nama Usia Hubungan Status Keehatan
3. Keluhan Utama
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………………………………………………………………………………………………………………………b. Riwayat Kesehatan Masa Lalu1) Prenatal............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................................................................................................................................... ..........................................................................................................................................................................................................................................................................................................................................................................2) Natal.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. .......................................................................................................................................................................................................................................................................................................................................................................... ..........................................................................................................................................................................................................................................................................................................................................................................3) Postnatal (APGAR).......................................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................................................................................................................................... c. Riwayat Penyakit Keluarga (Genogram)
4. Riwayat Imunisasi (Imunisasi Lengkap)No Jenis Imunisasi Waktu Pemberian Frekuensi Reaksi setelah pemberian1 BCG2 DPT (I, II,III)3 Polio (I,II,III,IV)4 Campak5 Hepatitis
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5. Riwayat Tumbuh Kembang a. Pertumbuhan Fisik
- Berat badan lahir : ………………kg- Panjang badan lahir:……………. cm.
b. Perkembangan Tiap tahap1. Berguling : …………… bulan2. Duduk : …………… bulan3. Merangkak : …………… bulan4. Berdiri : …………… tahun5. Berjalan : …………… tahun6. Senyum kepada orang lain pertama kali : ……………...........................................................................7. Bicara pertama kali : …………………………………………………………………………………………...8. Berpakaian tanpa bantuan : …………………………………………………………………………………….
c. Riwayat Nutrisi...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
6. Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)a. Psikososial Anak dan Reaksi Hospitalisasi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................b. Pola Nutrisi-Metabolik
Sebelum Sakit Saat Sakit
c. Pola EliminasiSebelum Sakit Saat Sakit
d. Pola aktivitas dan latihan 1) Aktivitas
Kemampuan Perawatan Diri 0 1 2 3 4Makan dan minumMandiToiletingBerpakaianBerpindah
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0: mandiri, 1: Alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total 2) Latihan dan Olahraga
Sebelum Sakit Saat Sakit
e. Pola Tidur dan Istirahat Sebelum Sakit Saat Sakit
f. Pola Nilai-Kepercayaan............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................g. Rekreasi.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4.Pengkajian Fisika.Keadaan umum : Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma GCS: Verbal:……, Psikomotor:……., Mata :……… TB: ................, BB:................, IMT: ............
b.Tanda-tanda Vital : Nadi = ………......, Suhu =…………. , TD =………....…, RR =……...c. Keadaan fisik
1) Kepala, Wajah, dan Mata 4) Mulut & Bibir
2) Hidung 5) Tenggorokan & Leher
3) Telinga 6) Genetalia
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7) Pemeriksaan ThoraxInspeksi
Palpasi
Perkusi
Auskultasi
8) Abdomen:Inspeksi
Auskultasi
Perkusi
Palpasi
9) Ekstremitas:.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
10) NeurologiI: Olfaktorius (Penciuman)
II: Opticus(Penglihatan)III, IV, VI: Oculomotorius, Trochlearis, Abducens(Kontraksi pupil dan pergerakan bola mata)V: Trigeminus (Otot dagu)
VII: Facialis (Gerakan wajah)VIII: Vestibulokoklearis(Pendengaran)IX dan X: Glosopharingeus dan Vagus(Refleks menelan dan muntah)XI: Assesorius(Otot Bahu dan leher)XII: Hypoglossus
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(Devasi lidah)d. Pemeriksaan Penunjang 1) Data Laboratorium
Tanggal Keterangan Hasil Pemeriksaan Nilai Normal
2)Pemeriksaan RadiologiTanggal Jenis Pemeriksaan Hasil Pemeriksaan
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ASUHAN KEPERAWATAN1. Analisa Data
No Data Obyektif Data Subyektif Etiologi Masalah
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2. Rencana KeperawatanNo Diagnosa Keperawatan NOC NIC
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3. Catatan PerkembanganTgl No. Dx Jam Intervensi Evaluasi
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