BAB III ASUHAN KEPERAWATAN PADA ANAK I.
BAB III
ASUHAN KEPERAWATAN PADA ANAK
I.
PENGKAJIAN
A. Data Demografi
1.
Klien/Pasien
b.
Tanggal pengkajian
: ...................................
c.
Tanggal masuk
: ...................................
d.
Ruangan
: ..................................
e.
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
:
…………………………
....................................
f. No. telepon
:
………………….........
B. Riwayat Klien
1. Riwayat penyakit klien sebelumnya : ……………………
…………………………………………………….................
............................................................................................
2. Riwayat kehamilan
(ANC,
masalah
kesehatan
selama
: .........................................................................................
.........................................................................................
kehamilan,
dll)
3. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit
persalinan,
dll):
……………………………………………………............................................................
.......................................................................................................................................
......................................................................................................................................
4. Riwayat imunisasi
Hepatitis B
(lengkapi)
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 ……..........................................
5. Riwayat alergi
: …………….................................
6. Riwayat pemakaian obat-obatan : ...…….......................
7. Riwayat tumbuh kembang (Sejak lahir hingga sekarang):
Motorik halus: .....................................................................
............................................................................................
Motorik kasar: ....................................................................
............................................................................................
Bahasa: ..............................................................................
............................................................................................
Personal sosial: ..................................................................
............................................................................................
Reflek primitif (Neonatus): .................................................
............................................................................................
C. Riwayat Kesehatan Keluarga
1.
Riwayat penyakit dalam keluarga:
………………………………………………........…..................................................
....
………………………………………………………………………………………........
...........................................................................................................................
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):
…………………………………………………………...............................................
.................................................................................................................................
.................................................................................................................................
b. Pemeriksaaan Tanda-Tanda Vital
1) Pernapasan
: ....................
2) Suhu
: .....................
3) Nadi
: .....................
4) Tekanan Darah: ...................
5) Saturasi oksigen: ..................
c.
Penggunaan alat bantu napas (Oksigen, CPAP, dll)
................................................................................................................................
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): ...........................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
h.
i.
j.
Kebutuhan kalori
: ........................................................
Jenis makanan
: ...................................................................................
Makanan yang disukai
: ...................................................................................
Alergi makanan
: ..................................................................................
Kesulitan saat makan
: ................................................................................
..............................................................................................................................
k.
Kebiasaan khusus saat makan : .........................................................................
.............................................................................................................................
l.
Keluhan (mual, muntah, kembung, anoreksia, dsb...):
.............................................................................................................................
.............................................................................................................................
a.
Kebutuhan cairan 24 jam:............................................
b.
Balance cairan (hitung jumlah dan jenis cairan masuk dan keluar):
.............................................................................................................................
..............................................................................................................................
..............................................................................................................................
c.
Diuresis
: ......................................................
d.
Rute cairan masuk (oral, parenteral, enteral,
dsb) ........................................................................................................................
................................................................................................................................
........
e.
Jenis cairan (ASI/susu formula/infus/air putih, dsb):
................................................................................................................................
................................................................................................................................
f.
Keluhan : ..............................................................................................................
................................................................................................................................
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)
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
....
6. Psikososial anak dan keluarga
a.
Respon hospitalisasi (rewel, tenang).......................................................................
.................................................................................................................................
b.
Kecemasan (anak dan orang tua) ..........................................................................
.................................................................................................................................
.................................................................................................................................
c.
Koping klien/keluarga dalam menghadapi masalah
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
d.
Pengetahuan orang tua tentang penyakit anak
.................................................................................................................................
.................................................................................................................................
e.
Keterlibatan orang tua dalam perawatan anak .......................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
f.
Konsep diri
.................................................................................................................................
.................................................................................................................................
g.
Spiritual (kebiasaan ibadah, keyakinan, nilai, budaya)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
h.
Adakah terapi lain selain medis yang dilakukan .....................................................
.................................................................................................................................
7.
Pemeriksaan penunjang (laboratorium, radiologi)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
....
8.
Terapi: .....................................................................................................................
.................................................................................................................................
.................................................................................................................................
...............
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
/JAM
TUJUAN
INTERVENSI
TINDAKAN
TTD
12. IMPLEMENTASI
NO No. DX KEP
TGL
/JAM
IMPLEMENTASI
RESPON
TTD
13. EVALUASI (perkembangan setiap hari dalam bentuk SOAP)
NO
TGL/JAM
DX KEP
EVALUASI
S:
O:
A:
P:
TTD
ASUHAN KEPERAWATAN PADA ANAK
I.
PENGKAJIAN
A. Data Demografi
1.
Klien/Pasien
b.
Tanggal pengkajian
: ...................................
c.
Tanggal masuk
: ...................................
d.
Ruangan
: ..................................
e.
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
:
…………………………
....................................
f. No. telepon
:
………………….........
B. Riwayat Klien
1. Riwayat penyakit klien sebelumnya : ……………………
…………………………………………………….................
............................................................................................
2. Riwayat kehamilan
(ANC,
masalah
kesehatan
selama
: .........................................................................................
.........................................................................................
kehamilan,
dll)
3. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit
persalinan,
dll):
……………………………………………………............................................................
.......................................................................................................................................
......................................................................................................................................
4. Riwayat imunisasi
Hepatitis B
(lengkapi)
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 ……..........................................
5. Riwayat alergi
: …………….................................
6. Riwayat pemakaian obat-obatan : ...…….......................
7. Riwayat tumbuh kembang (Sejak lahir hingga sekarang):
Motorik halus: .....................................................................
............................................................................................
Motorik kasar: ....................................................................
............................................................................................
Bahasa: ..............................................................................
............................................................................................
Personal sosial: ..................................................................
............................................................................................
Reflek primitif (Neonatus): .................................................
............................................................................................
C. Riwayat Kesehatan Keluarga
1.
Riwayat penyakit dalam keluarga:
………………………………………………........…..................................................
....
………………………………………………………………………………………........
...........................................................................................................................
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):
…………………………………………………………...............................................
.................................................................................................................................
.................................................................................................................................
b. Pemeriksaaan Tanda-Tanda Vital
1) Pernapasan
: ....................
2) Suhu
: .....................
3) Nadi
: .....................
4) Tekanan Darah: ...................
5) Saturasi oksigen: ..................
c.
Penggunaan alat bantu napas (Oksigen, CPAP, dll)
................................................................................................................................
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): ...........................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
h.
i.
j.
Kebutuhan kalori
: ........................................................
Jenis makanan
: ...................................................................................
Makanan yang disukai
: ...................................................................................
Alergi makanan
: ..................................................................................
Kesulitan saat makan
: ................................................................................
..............................................................................................................................
k.
Kebiasaan khusus saat makan : .........................................................................
.............................................................................................................................
l.
Keluhan (mual, muntah, kembung, anoreksia, dsb...):
.............................................................................................................................
.............................................................................................................................
a.
Kebutuhan cairan 24 jam:............................................
b.
Balance cairan (hitung jumlah dan jenis cairan masuk dan keluar):
.............................................................................................................................
..............................................................................................................................
..............................................................................................................................
c.
Diuresis
: ......................................................
d.
Rute cairan masuk (oral, parenteral, enteral,
dsb) ........................................................................................................................
................................................................................................................................
........
e.
Jenis cairan (ASI/susu formula/infus/air putih, dsb):
................................................................................................................................
................................................................................................................................
f.
Keluhan : ..............................................................................................................
................................................................................................................................
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)
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
....
6. Psikososial anak dan keluarga
a.
Respon hospitalisasi (rewel, tenang).......................................................................
.................................................................................................................................
b.
Kecemasan (anak dan orang tua) ..........................................................................
.................................................................................................................................
.................................................................................................................................
c.
Koping klien/keluarga dalam menghadapi masalah
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
d.
Pengetahuan orang tua tentang penyakit anak
.................................................................................................................................
.................................................................................................................................
e.
Keterlibatan orang tua dalam perawatan anak .......................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
f.
Konsep diri
.................................................................................................................................
.................................................................................................................................
g.
Spiritual (kebiasaan ibadah, keyakinan, nilai, budaya)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
h.
Adakah terapi lain selain medis yang dilakukan .....................................................
.................................................................................................................................
7.
Pemeriksaan penunjang (laboratorium, radiologi)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
....
8.
Terapi: .....................................................................................................................
.................................................................................................................................
.................................................................................................................................
...............
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
/JAM
TUJUAN
INTERVENSI
TINDAKAN
TTD
12. IMPLEMENTASI
NO No. DX KEP
TGL
/JAM
IMPLEMENTASI
RESPON
TTD
13. EVALUASI (perkembangan setiap hari dalam bentuk SOAP)
NO
TGL/JAM
DX KEP
EVALUASI
S:
O:
A:
P:
TTD