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

.........................................

...............................


....................................................

.

.

....................................................

.........................................

...............................

....................................................

.

.

....................................................

.........................................

...............................

....................................................

.

.

....................................................

.........................................

...............................

....................................................

.

.

....................................................

.........................................

...............................

....................................................

.

.

....................................................

.........................................

...............................

....................................................

.

.

....................................................

.........................................

...............................

....................................................

.

.

....................................................

.........................................

...............................

....................................................

.

.

.......................................................

.........................................

...............................

..............................................

.

.

....................................................

.........................................

...............................

....................................................

.

.

.................................................... ..

.........................................

...............................

..................................................

.

.

.......................................................

.........................................

...............................

.................................................

.

.

....................................................

.........................................

...............................

....................................................

.

.

....................................................

.........................................

...............................

....................................................

.

.

.......................................................

.........................................

...............................

.................................................

.

.

....................................................

Pediatric PSIK FK UNLAM®

Indikasi

.........................................

...............................

.

.

.........................................

...............................

.

.

.........................................

...............................

.

.

.........................................

...............................

.

.

.........................................

...............................

.

...............................

.........................................

.

.

...............................

.........................................

.

.

...............................

.........................................

.

.

...............................

.........................................

.

.

...............................

.........................................

. .............................

.

...

.........................................

...............................

. ....................................... .
...

...............................

.........................................

.

.

...............................

.........................................

.

.

...............................

.........................................

.

.
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

Dokumen yang terkait

ANALISIS KOMPARATIF PENDAPATAN DAN EFISIENSI ANTARA BERAS POLES MEDIUM DENGAN BERAS POLES SUPER DI UD. PUTRA TEMU REJEKI (Studi Kasus di Desa Belung Kecamatan Poncokusumo Kabupaten Malang)

23 307 16

FREKUENSI KEMUNCULAN TOKOH KARAKTER ANTAGONIS DAN PROTAGONIS PADA SINETRON (Analisis Isi Pada Sinetron Munajah Cinta di RCTI dan Sinetron Cinta Fitri di SCTV)

27 310 2

MANAJEMEN PEMROGRAMAN PADA STASIUN RADIO SWASTA (Studi Deskriptif Program Acara Garus di Radio VIS FM Banyuwangi)

29 282 2

PENYESUAIAN SOSIAL SISWA REGULER DENGAN ADANYA ANAK BERKEBUTUHAN KHUSUS DI SD INKLUSI GUGUS 4 SUMBERSARI MALANG

64 523 26

STRATEGI PEMERINTAH DAERAH DALAM MEWUJUDKAN MALANG KOTA LAYAK ANAK (MAKOLA) MELALUI PENYEDIAAN FASILITAS PENDIDIKAN

73 431 39

ANALISIS PROSPEKTIF SEBAGAI ALAT PERENCANAAN LABA PADA PT MUSTIKA RATU Tbk

273 1263 22

PENERIMAAN ATLET SILAT TENTANG ADEGAN PENCAK SILAT INDONESIA PADA FILM THE RAID REDEMPTION (STUDI RESEPSI PADA IKATAN PENCAK SILAT INDONESIA MALANG)

43 322 21

KONSTRUKSI MEDIA TENTANG KETERLIBATAN POLITISI PARTAI DEMOKRAT ANAS URBANINGRUM PADA KASUS KORUPSI PROYEK PEMBANGUNAN KOMPLEK OLAHRAGA DI BUKIT HAMBALANG (Analisis Wacana Koran Harian Pagi Surya edisi 9-12, 16, 18 dan 23 Februari 2013 )

64 565 20

PEMAKNAAN BERITA PERKEMBANGAN KOMODITI BERJANGKA PADA PROGRAM ACARA KABAR PASAR DI TV ONE (Analisis Resepsi Pada Karyawan PT Victory International Futures Malang)

18 209 45

STRATEGI KOMUNIKASI POLITIK PARTAI POLITIK PADA PEMILIHAN KEPALA DAERAH TAHUN 2012 DI KOTA BATU (Studi Kasus Tim Pemenangan Pemilu Eddy Rumpoko-Punjul Santoso)

119 459 25