ASUHAN KEPERAWATAN PADA ANAK DENGAN HIDR
ASUHAN KEPERAWATAN PADA ANAK DENGAN HIDRONEPROSIS
DI RUANG PEDIATRIC INTENSIVE CARE UNIT
Tanggal Pengkajian ............................................
I.
IDENTITAS
A. Data Pasien
Nama
:......................................................................
Tempat Tanggal Lahir
:......................................................................
Umur
:......................................................................
No. Rekam Medis
:......................................................................
Diagnosis Medis
:......................................................................
B. Data Penanggung Jawab
Nama Ayah/ Nama Ibu
:......................................................................
Pendidikan terakhir Ayah
:......................................................................
Pekerjaan ayah
:......................................................................
Pendidikan terakhir Ibu
:......................................................................
Pekerjaan Ibu
:......................................................................
Alamat
:......................................................................
Kultur
:......................................................................
Agama
:......................................................................
II. RIWAYAT PENYAKIT
A. Keluhan Utama
Alasan Masuk Rumah Sakit:
........................................................................................................................
........................................................................................................................
........................................................................................................................
Keluhan Saat Ini:
........................................................................................................................
........................................................................................................................
........................................................................................................................
Pediatric PSIK FK UNLAM®
B. Riwayat Penyakit Sekarang
........................................................................................................................
........................................................................................................................
........................................................................................................................
C. Riwayat Penyakit Dahulu
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
III. RIWAYAT KESEHATAN KELUARGA
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
A. Genogram
Pediatric PSIK FK UNLAM®
IV. PEMERIKSAAN FISIK
A. Keadaan Umum anak .........................................................
B. Tingkat Kesadaran : ..................................
GCS ……………………
C. Tanda- tanda vital
Temperatur ...........................
Pulse .................................
Respirasi ............................
TD ..................................
SpO2 ............................
D. Pemeriksaan Skala Nyeri
............................................................................................................
............................................................................................................
............................................................................................................
E. Pemeriksaan B1 bearth (Pernafasan)
Frekuensi napas : …………… kedalaman : ……………irama : ……….....
Bunyi Napas:.................................................................................................
Batuk:............................................................................................................
Pemeriksaan Thorak:
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
F. Pemeriksaan B2 blood (Kardiovaskuler)
Frekuensi nadi ………………….irama ……………… TD………………..
Capillary refill Time ......................................................................................
Palpitasi..........................................................................................................
Pediatric PSIK FK UNLAM®
Pemeriksaan Thoraks
........................................................................................................................
........................................................................................................................
........................................................................................................................
G. Pemeriksaan B3 brain (Persyarafan)
Pengkajian FOUR SCORE
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Rambut dan Kepala:
........................................................................................................................
........................................................................................................................
Kaku Kuduk...................................................................................................
........................................................................................................................
Posisi bola mata : ...........................................................................................
Gerakan mata : ...............................................................................................
Konjungtiva : .................................................................................................
Kornea : .........................................................................................................
Sklera : ..........................................................................................................
Pupil :............................................................................................................
H. Pemeriksaan B4 bladder (Perkemihan)
Frekuensi BAK:......................../hari, Jumlah Urine:........................ cc
Warna Urine: ........................
Penggunaan Alat bantu berkemih:................................................................
Kondisi Blast:................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Tanggal defekasi terakhir:........................
Frekuensi BAB:.........../hari, Konsistensi:..............., Warna:......................
Pediatric PSIK FK UNLAM®
Penggunaan Alat bantu (Laksatif):................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
I. Pemeriksaan B5 bowel (Pencernaan)
Penilaiaan Nausea dengan Menggunakan Barf Scale
(Baxter Animated Retching Faces Scale)
........................................................................................................................
........................................................................................................................
........................................................................................................................
Intake Nutrisi Sebelum dan Saat Sakit
Makanan
........................................................................................................................
........................................................................................................................
Minuman
........................................................................................................................
........................................................................................................................
Nafsu Makan
........................................................................................................................
........................................................................................................................
Pemeriksaan Abdomen
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Pediatric PSIK FK UNLAM®
J. Pemeriksaan B6 bone (Muskuloskeletal dan Integumen)
Rentang gerak
:......................................................................
Skala kekuatan otot
:......................................................................
Bentuk tulang belakang
:......................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Pediatric PSIK FK UNLAM®
V. OBAT-OBATAN
N
o
Obat
Dosis
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Pediatric PSIK FK UNLAM®
Indikasi
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VI. PEMERIKSAAN PENUNJANG
Tanggal 29-08-2016: Jam 22.26
PEMERIKSAAN
HEMATOLOGI
HASIL
NILAI RUJUKAN
Pediatric PSIK FK UNLAM®
SATUAN
METODA
Hemoglobin
Leukosit
Eritrosit
14
14.9
4.80
12.00 - 15.60
4.65 - 10.3
4.00 - 5.30
g/dl
ribu/ul
juta/ul
Colorimetric
Impedance
Impedance
Analyze
Calculates
Impedance
Analyze
Calculates
Hematokrit
40.6
37.00 - 47.00
vol%
Trombosit
501
150 - 356
ribu/ul
RDW-CV
16.7
12.1 - 14.0
%
MCV
84.6
75.0 - 96.0
fl
MCH
29.1
28.0 - 32.0
pg
MCHC
34.4
33.0 – 37.0
%
71.5
18.6
9.9
10.70
2.8
1.4
50.0 – 70.0
25.0 – 40.0
4.0 – 11.0
2.50 – 7.00
1.25 – 4.0
%
%
%
ribu/ul
ribu/ul
ribu/ul
Impedance
Impedance
Impedance
Impedance
Impedance
Impedance
241
213
3.8
0 - 46
0 - 45
3.5-5.5
U/I
U/I
g/dl
IFCC
IFCC
biuret
27
10 – 50
mg/dl
MCV, MCH, MCHC
HITUNG JENIS
Gran%
Limfosit%
MID%
Gran#
Limfosit#
MID#
KIMIA
HATI
SGOT
SGPT
Albumin
GINJAL
Ureum
Creatinin
1.0
0.6 – 1.2
ELEKTROLIT
Natrium
134
135 – 146
Kalium
1.1
3.4 – 5.4
Chlorida
101
95 – 100
Tanggal 30-08-2016: Jam 11.45
PEMERIKSAAN
GULA DARAH
Gula darah sewaktu
HATI
SGOT
Analyze
Calculates
Analyze
Calculates
Analyze
Calculates
mg/dl
MoodifBerhelot
Jaffe
mmol/I
mmol/I
mmol/I
ISE
ISE
ISE
HASIL
NILAI RUJUKAN
SATUAN
METODA
115
DI RUANG PEDIATRIC INTENSIVE CARE UNIT
Tanggal Pengkajian ............................................
I.
IDENTITAS
A. Data Pasien
Nama
:......................................................................
Tempat Tanggal Lahir
:......................................................................
Umur
:......................................................................
No. Rekam Medis
:......................................................................
Diagnosis Medis
:......................................................................
B. Data Penanggung Jawab
Nama Ayah/ Nama Ibu
:......................................................................
Pendidikan terakhir Ayah
:......................................................................
Pekerjaan ayah
:......................................................................
Pendidikan terakhir Ibu
:......................................................................
Pekerjaan Ibu
:......................................................................
Alamat
:......................................................................
Kultur
:......................................................................
Agama
:......................................................................
II. RIWAYAT PENYAKIT
A. Keluhan Utama
Alasan Masuk Rumah Sakit:
........................................................................................................................
........................................................................................................................
........................................................................................................................
Keluhan Saat Ini:
........................................................................................................................
........................................................................................................................
........................................................................................................................
Pediatric PSIK FK UNLAM®
B. Riwayat Penyakit Sekarang
........................................................................................................................
........................................................................................................................
........................................................................................................................
C. Riwayat Penyakit Dahulu
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
III. RIWAYAT KESEHATAN KELUARGA
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
A. Genogram
Pediatric PSIK FK UNLAM®
IV. PEMERIKSAAN FISIK
A. Keadaan Umum anak .........................................................
B. Tingkat Kesadaran : ..................................
GCS ……………………
C. Tanda- tanda vital
Temperatur ...........................
Pulse .................................
Respirasi ............................
TD ..................................
SpO2 ............................
D. Pemeriksaan Skala Nyeri
............................................................................................................
............................................................................................................
............................................................................................................
E. Pemeriksaan B1 bearth (Pernafasan)
Frekuensi napas : …………… kedalaman : ……………irama : ……….....
Bunyi Napas:.................................................................................................
Batuk:............................................................................................................
Pemeriksaan Thorak:
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
F. Pemeriksaan B2 blood (Kardiovaskuler)
Frekuensi nadi ………………….irama ……………… TD………………..
Capillary refill Time ......................................................................................
Palpitasi..........................................................................................................
Pediatric PSIK FK UNLAM®
Pemeriksaan Thoraks
........................................................................................................................
........................................................................................................................
........................................................................................................................
G. Pemeriksaan B3 brain (Persyarafan)
Pengkajian FOUR SCORE
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Rambut dan Kepala:
........................................................................................................................
........................................................................................................................
Kaku Kuduk...................................................................................................
........................................................................................................................
Posisi bola mata : ...........................................................................................
Gerakan mata : ...............................................................................................
Konjungtiva : .................................................................................................
Kornea : .........................................................................................................
Sklera : ..........................................................................................................
Pupil :............................................................................................................
H. Pemeriksaan B4 bladder (Perkemihan)
Frekuensi BAK:......................../hari, Jumlah Urine:........................ cc
Warna Urine: ........................
Penggunaan Alat bantu berkemih:................................................................
Kondisi Blast:................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Tanggal defekasi terakhir:........................
Frekuensi BAB:.........../hari, Konsistensi:..............., Warna:......................
Pediatric PSIK FK UNLAM®
Penggunaan Alat bantu (Laksatif):................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
I. Pemeriksaan B5 bowel (Pencernaan)
Penilaiaan Nausea dengan Menggunakan Barf Scale
(Baxter Animated Retching Faces Scale)
........................................................................................................................
........................................................................................................................
........................................................................................................................
Intake Nutrisi Sebelum dan Saat Sakit
Makanan
........................................................................................................................
........................................................................................................................
Minuman
........................................................................................................................
........................................................................................................................
Nafsu Makan
........................................................................................................................
........................................................................................................................
Pemeriksaan Abdomen
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Pediatric PSIK FK UNLAM®
J. Pemeriksaan B6 bone (Muskuloskeletal dan Integumen)
Rentang gerak
:......................................................................
Skala kekuatan otot
:......................................................................
Bentuk tulang belakang
:......................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Pediatric PSIK FK UNLAM®
V. OBAT-OBATAN
N
o
Obat
Dosis
.........................................
...............................
....................................................
.
.
....................................................
.........................................
...............................
....................................................
.
.
....................................................
.........................................
...............................
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....................................................
.........................................
...............................
....................................................
.
.
.......................................................
.........................................
...............................
.................................................
.
.
....................................................
Pediatric PSIK FK UNLAM®
Indikasi
.........................................
...............................
.
.
.........................................
...............................
.
.
.........................................
...............................
.
.
.........................................
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. ....................................... .
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.........................................
.
.
...............................
.........................................
.
.
...............................
.........................................
.
.
VI. PEMERIKSAAN PENUNJANG
Tanggal 29-08-2016: Jam 22.26
PEMERIKSAAN
HEMATOLOGI
HASIL
NILAI RUJUKAN
Pediatric PSIK FK UNLAM®
SATUAN
METODA
Hemoglobin
Leukosit
Eritrosit
14
14.9
4.80
12.00 - 15.60
4.65 - 10.3
4.00 - 5.30
g/dl
ribu/ul
juta/ul
Colorimetric
Impedance
Impedance
Analyze
Calculates
Impedance
Analyze
Calculates
Hematokrit
40.6
37.00 - 47.00
vol%
Trombosit
501
150 - 356
ribu/ul
RDW-CV
16.7
12.1 - 14.0
%
MCV
84.6
75.0 - 96.0
fl
MCH
29.1
28.0 - 32.0
pg
MCHC
34.4
33.0 – 37.0
%
71.5
18.6
9.9
10.70
2.8
1.4
50.0 – 70.0
25.0 – 40.0
4.0 – 11.0
2.50 – 7.00
1.25 – 4.0
%
%
%
ribu/ul
ribu/ul
ribu/ul
Impedance
Impedance
Impedance
Impedance
Impedance
Impedance
241
213
3.8
0 - 46
0 - 45
3.5-5.5
U/I
U/I
g/dl
IFCC
IFCC
biuret
27
10 – 50
mg/dl
MCV, MCH, MCHC
HITUNG JENIS
Gran%
Limfosit%
MID%
Gran#
Limfosit#
MID#
KIMIA
HATI
SGOT
SGPT
Albumin
GINJAL
Ureum
Creatinin
1.0
0.6 – 1.2
ELEKTROLIT
Natrium
134
135 – 146
Kalium
1.1
3.4 – 5.4
Chlorida
101
95 – 100
Tanggal 30-08-2016: Jam 11.45
PEMERIKSAAN
GULA DARAH
Gula darah sewaktu
HATI
SGOT
Analyze
Calculates
Analyze
Calculates
Analyze
Calculates
mg/dl
MoodifBerhelot
Jaffe
mmol/I
mmol/I
mmol/I
ISE
ISE
ISE
HASIL
NILAI RUJUKAN
SATUAN
METODA
115