ASKEP

PENGKAJIAN KEPERAWATAN ANAK
Nama Mahasiswa
: ...................................................
NIM
: ...................................................
Kelompok
: ...................................................
Tanggal Pengkajian : ...................................................

A. IDENTITAS DATA
1. DATA KLIEN
Nama
Tempat / Tanggal lahir
Umur
Agama
No. Rekam Medik
Diagnosa Medis
: ......................................................................
: ......................................................................
: ......................................................................
: ......................................................................
: ......................................................................
: ......................................................................
2. DATA PENANGGUNG JAWAB

Nama Ayah/lbu
: .....................................................................
Pekerjaan Ayah
: ...............................................................
Pendidikan Terakhir Ayah : ...............................................................
Pekerjaan lbu
: .....................................................................
Pendidikan Ibu
: .....................................................................
Alamat
: .....................................................................
Kultur
: .....................................................................
Agama
: .....................................................................
B. RIWAYAT PENYAKIT
1. Keluhan Utama
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2. Riwayat Penyakit Sekarang
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3. Riwayat Penyakit Dahulu

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4. Riwayat Penyakit Keluarga

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C. GENOGRAM
D. RIWAYAT KEHAMILAN DAN KELAHIRAN

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E. RIWAYAT SOSIAL
1. Sistem pendukung / keluarga terdekat yang dapat dihubungi
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2. Lingkungan rumah
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3. Problem sosial yang penting
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F. KEADAAN KESEHATAN SAAT INI

1. Diagnosis Medis
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2. Tindakan Operasi
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3. Status Nutrisi
Sebelum masuk RS :
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Sesudah masuk RS :
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4. Status Cairan
Sebelum masuk RS :
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Sesudah masuk RS :
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5. Obat- obatan
Obat
Rute Pemberian
Dosis
Indikasi
6. Aktivitas
Sebelum Sakit :
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Sesudah Sakit :
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7. Tindakan Keperawatan yang Telah Dilakukan
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G. PEMERIKSAAN FISIK
1. Keadaan Umum = ....
....
....
2. Kesadaran
= ....
....
....
....
3. Tanda Vital
= Nadi
Suhu
RR
:
:
:
x/ menit
C
x/ menit
4. Skala Nyeri
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5. Kepala/Leher
Inspeksi
Rambut
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Kepala
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Palpasi
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6. Wajah
Inspeksi
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Palpasi
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7. Leher
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8. Ekstremitas
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9. THT
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10. Abdomen
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11. Toraks
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12. Jantung
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13. Tumbuh Kembang
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H. INFORMASI LAIN
Status Imunisasi: .......................................................................................................
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I. PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium
PEMERIKSAAN
HASIL
NILAI RUJUKAN
SATUAN
METODA
HEMATOLOGI
Hemoglobin
12,00 - 16,00
g/dl
Colorimetric
Leokosit
4,0 10,5
Ribu/ul
Impedance
Eritrosit
3,90 - 5,50
Juta/ul
Impedance
Analyzer
Hematokrit
37,00 47,00
vol%
Calculates
Trombosit
150 450
Ribu/ul
Impedance
Analyzer
PCW-CV
11,5 14,7
%
Calculates
PCV, MCH, MCHC
Analyzer
PCV
80,0 97,0
fl
Calculates
MCH
Analyzer
27,0 32,0
pg
Calculates
Analyzer
MCHC
32,0 38,0
%
Calculates
HITUNG JENIS
Basofil %
0,0-1,0
%
Eosinofil %
1,0- 3,0
%
Gran %
50,0-70,0
%
Impedence
Limposit %
25,0-40,0
%
Impedence
Monosit %
3,0-9,0
%
Basofil #
<1
ribu/ul
Eosinofil #
<3
ribu/ul
Gran #
Limfosit #
Monosit #
2,50-40,0
1,25-4,0
0,30-1,00
ribu/ul
ribu/ul
ribu/ul
2. Foto
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ANALISIS DATA
Nama Anak:
Ruang:
No. Mrs:
Data
Objektif
Subjektif
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Etiologi
Masalah
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Etiologi
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PRIORITAS MASALAH
Nama Klien
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Umur
: ..............................................
Ruangan/Kamar : ..............................................
No.
Masalah Keperawatan
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Paraf
Tanggal
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Ditemukan
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Teratasi
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(Nama Perawat)
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RENCANA KEPERAWATAN
No.
Nama Klien
Nama Mahasiswa
Ruang/Kamar
NIM
Diagnosis Medis
Paraf
Diagnosa Keperawatan
Tujuan dan Kriteria Hasil
Rencana Keperawatan
Rasional
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No.
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Rencana Keperawatan
Rasional
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No.
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Rencana Keperawatan
Rasional
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No.
Dx.
Waktu
Tanggal/Jam
.
TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN
Tindakan Keperawatan
TT
Waktu
Catatan Perkembangan
Tanggal/Jam
(SOAP)
TT
Kep.
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No.
Dx.
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Waktu
Tanggal/Jam
TT
Waktu
Tanggal/Jam
(SOAP)
TT
Kep.
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No.
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Waktu
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Dx.
Tanggal/Jam
TT
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Waktu
TT
Tanggal/Jam
(SOAP)
Kep.
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PENGKAJIAN KEPERAWATAN ANAK

Tanggal Pengkajian : ...................................................

2. DATA PENANGGUNG JAWAB

3. Riwayat Penyakit Dahulu

4. Riwayat Penyakit Keluarga

D. RIWAYAT KEHAMILAN DAN KELAHIRAN

F. KEADAAN KESEHATAN SAAT INI

Tujuan dan Kriteria Hasil

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