ASUHAN KEPERAWARAN PADA An.

A
DI RUANG RSU DR. SLAMET GARUT

Nama mahasiswa :
Tanggal pengkajian :

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 : ...................................... (jam ............)
8. Tgl pengkajian :……………………………………………………………
9. Diagnosa medik :……………………………………………………………

B. Identitas Orang tua

1. Ayah
a. N a m a : ……………………………………………………………
b. U s i a : ……………………………………………………………
c. Pendidikan : ……………………………………………………………
d. Pekerjaan : ……………………………………………………………
e. A g a m a : ……………………………………………………………
f. Alamat : ……………………………………………………………
2. Ibu
a. N a m a : ……………………………………………………………
b. U s i a : ……………………………………………………………
c. Pendidikan : ……………………………………………………………
d. Pekerjaan : ……………………………………………………………
e. Agama : ……………………………………………………………
f. Alamat : ……………………………………………………………

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 C. Identitas Saudara Kandung
No Nama Usia Hubungan Status Kesehatan

II. Riwayat Kesehatan

A. Riwayat Kesehatan Sekarang :
Riwayat Keluhan Utama :
…………………………………………………………………………………………………
……………………………………………………………………………………………
………………………………………………………………………………………………
Keluhan Pada Saat Pengkajian :
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
B. Riwayat Kesehatan Lalu (khusus untuk anak usia 0 – 5 tahun)
1. Prenatal care
a. Ibu memeriksakan kehamilannya setiap minggu di…………………….
Keluhan selama hamil yang dirasakan oleh ibu, tapi oleh dokter dianjurkan untuk
………………………………………………………………………………………
b. Riwayat terkena radiasi : ……………………………………….
c. Riwayat berat badan selama hamil : …………………………………..
e. Riwayat Imunisasi TT : ………………………………………..
f. Golongan darah ibu ………….. Golongan darah ayah …………..
2. Natal
a, Tempat melahirkan : ………………………………………….
b. Jenis persalinan : …………………………………………….
c. Penolong persalinan : …………………………………………
e. Komplikasi yang dialami oleh ibu pada saat melahirkan dan setelah melahirkan :
....................................................................................................................................

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 3. Post natal
a. Kondisi bayi : …………………………….
b. Anak pada saat lahir tidak mengalami : ………………………………………
(Untuk semua Usia)
¤ Klien pernah mengalami penyakit : ……………….pada umur : …………………..
diberikan obat oleh : …………………………………………..
¤ Riwayat kecelakaan : ………………………………………………………………
¤ Riwayat mengkonsumsi obat-obatan berbahaya tanpa anjuran dokter dan menggunakan
zat/subtansi kimia yang berbahaya : ………………………………………………….
¤ Perkembangan anak dibanding saudara-saudaranya : .................................................
C. Riwayat Kesehatan Keluarga

IV. Riwayat Immunisasi (imunisasi lengkap)

Waktu Reaksi setelah
NO Jenis immunisasi Frekuensi Frekuensi
pemberian pemberian
1. BCG
2. DPT (I,II,III)
3. Polio (I,II,III,IV)
4. Campak
5. Hepatitis

V. Riwayat Tumbuh Kembang

Berat badan ………………kg
Tinggi badan ……………. cm.
Waktu tumbuh gigi …………………gigi
tanggal ………….........…………..…
Jumlah gigi ...................... buah.

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VI. Riwayat Nutrisi
Pemberian ASI
................................................................................................................................................
Pemberian susu formula
1. Alasan pemberian : ……………………………………………………………
2. Jumlah pemberian : ……………………………………………………………
3. Cara pemberian : ……………………………………………………………

VII. Riwayat Psikososial

¤ Anak tinggal bersama : ................................................ di : ..............................................
¤ Lingkungan berada di : ................................................
¤ Rumah dekat dengan : ................................................, tempat bermain ..........................
kamar klien : ................................................
¤ Rumah ada tangga : ................................................
¤ Hubungan antar anggota keluarga : ................................................
¤ Pengasuh anak : ................................................

VIII. Reaksi Hospitalisasi

A. Pengalaman keluarga tentang sakit dan rawat inap
- Ibu membawa anaknya ke RS karena : ................................................
- Apakah dokter menceritakan tentang kondisi anak : ................................................
- Perasaan orang tua saat ini : ................................................
- Orang tua selalu berkunjung ke RS : ................................................
- Yang akan tinggal dengan anak : ................................................
B. Pemahaman anak tentang sakit dan rawat inap
....................................................................................................................................
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 IX. Aktivitas sehari-hari
A. Nutrisi
Kondisi Sebelum Sakit Saat Sakit
1. Selera makan
B. Cairan
Kondisi Sebelum Sakit Saat Sakit
1. Jenis minuman
2. Frekuensi minum
3. Cara pemenuhan
C. Eliminasi (BAB & BAK)
Kondisi Sebelum Sakit Saat Sakit
1. Frekuensi
2. Konsistensi
3. Kesulitan
4. Obat pencahar

D. Istirahat tidur
Kondisi Sebelum Sakit Saat Sakit
- Siang
- Malam
2. Pola tidur
3. Kebiasaan sebelum tidur
4. Kesulitan tidur

E. Personal Hygiene
Kondisi Sebelum Sakit Saat Sakit
Mandi
Frekuensi
Cara
Cuci rambut
Frekuensi
Cara
Gunting kuku

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 Frekuensi
Cara
Gosok gigi
Frekuensi
Cara

F. Aktifitas/Mobilitas Fisik
Kondisi Sebelum Sakit Saat Sakit
Penggunaan alat Bantu aktifitas
Kesulitan pergerakan tubuh

XI. Pemeriksaan Fisik

Keadaan umum :
Kesadaran :
Tanda – tanda vital :
Tekanan darah : ..................................... mmHg
Denyut nadi : ..................................... x / menit
Suhu : ..................................... o C
Pernapasan : ..................................... x/ menit
Berat Badan :
Tinggi Badan :

PEMERIKSAAN PERSISTEM
SISTEM KARDIOVASKULER

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SISTEM RESPIRASI

SISTEM PENCERNAAN

SISTEM INTEGUMEN

SISTEM URINARIA

SISTEM MUSKULOSKELETAL

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 SISTEM PENGLIHATAN

SISTEM PENDENGARAN

SISTEM PENCIUMAN

1. Pemeriksaan Penunjang
Laboratorium
Nilai Pemeriksaan
No Jenis Pemeriksaan Hasil Pemeriksaan Keterangan
Normal

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 Hasil Foto Rontgen :
Hasil CT SCAN :
Hasil Foto Kontras :
Dan lain-lain

2. Therapy
Jenis Frekuensi
Obat Yang Cara Dosis Keterangan /
No Golongan Pemberian
diberikan Pemberian Obat Riwayat Obat
Obat Waktu (jam)

1.

2.

3.

4.

5.

6.

7.

8.

9.
Therapi cairan :

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A. ANALISA DATA
NO TGL DATA
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PROBLEM ETIOLOGI
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B. DIAGNOSA KEPERAWATAN
1. …………….
2. …………….
3. …………….
4. .....................
5. .....................
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 C. NURSING CARE PLANNING
TGL/JAM NO NOC NIC
DP
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 D. IMPLEMENTASI
TGL/JAM NO. IMPLEMENTASI EVALUASI (S O A P) PARAF
DP
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 E. CATATAN PERKEMBANGAN
TGL/JAM NO. EVALUASI (SOAP/ SOAPIE/ SOAPIER) PARAF
DP
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