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PENGKAJIAN KEPERAWATAN ANAK

Nama Mahasiswa : .................................................................................


NIM : .................................................................................
Tempat Praktek : .................................................................................

DATA IDENTITAS KLIEN


Nama : .................................................................................
Tempat / Tanggal lahir :..................................................................................
Nama Ayah :..................................................................................
Pekerjaan Ayah :..................................................................................
Pendidikan Ayah :..................................................................................
Nama Ibu : ..................................................................................
Pekerjaan lbu :..................................................................................
Pendidikan Ibu :..................................................................................
Alamat :..................................................................................
Suku :..................................................................................
Agama :..................................................................................
Diagnosis Medis : ..................................................................................
Tanggal MRS : ...............................Jam :
Tanggal Pengkajian : ...............................Jam :

I. KELUHAN UTAMA
a. Keluhan Masuk Rumah Sakit
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b. Keluhan Saat ini


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II. RIWAYAT KESEHATAN
a. Riwayat penyakit sekarang:
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b. Riwayat penyakit dahulu
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III. RIWAYAT IMUNISASI
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IV. RIWAYAT PENYAKIT KELUARGA
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GENOGRAM

Keterangan:

: Laki-laki : Klien

: Perempuan : Hubungan keluarga

: Meninggal : Tinggal serumah

V. 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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VI. KEADAAN KESEHATAN SAAT INI


1. Tindakan Operasi
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2. Status Nutrisi
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3. Status Cairan:
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4. Aktivitas Anak
Sebelum Masuk Rumah Sakit:
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Saat Dirawat Di Rumah Sakit:
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VII. PEMERIKSAAN FISIK


1. Keadaan Umum:
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2. Kesadaran : .......................................................................................................
 Tanda Vital :
 Tekanan darah : mmHg
 Nadi : x/ menit
 Suhu : °C
 RR : x/ menit
3. Pengkajian Skala Nyeri

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4. Kepala dan Leher
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5. Mata
Posisi bola mata : ...........................................................................................
Gerakan mata : ...............................................................................................
Konjungtiva : .............................................................................................................
Kornea : .....................................................................................................................
Sklera : ......................................................................................................................
Pupil :.........................................................................................................................
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6. THT
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7. Ekstremitas
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8. Toraks
Inspeksi : ................................................................................................................
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Palpasi : ................................................................................................................
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Perkusi : ................................................................................................................
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Auskultasi : ................................................................................................................
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9. Jantung
Inspeksi : ................................................................................................................
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Palpasi : ................................................................................................................
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Perkusi : ................................................................................................................
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Auskultasi : ................................................................................................................
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10. Abdomen
Inspeksi : ................................................................................................................
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Auskultasi : ................................................................................................................
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Perkusi : ................................................................................................................
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Palpasi : ................................................................................................................
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11. Genitalia
Frekuensi BAK: ......................../hari , Jumlah Urine: ........................ cc
Warna Urine: .............................................................................................................
Penggunaan Alat bantu berkemih: ............................................................................
Kondisi Blast: ............................................................................................................
Tanggal defekasi terakhir: .........................................................................................
Frekuensi BAB: .........../hari, Konsistensi: ..............., Warna: ......................
Penggunaan Alat bantu (Laksatif): ............................................................................
12. Tumbuh Kembang
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NCHS
a. BB/U
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b. TB/U
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c. BB/TB
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d. CDC 2000
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Lampiran 1. Daftar Obat-Obatan
No Obat Dosis Indikasi
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Lampiran 2. Hasil Pemeriksaan Laboraturium
Pemeriksaan Hasil Nilai Normal Satuan
HEMATOLOGI
Hemoglobin ................. 10.00-17.00 g/dl
Lekosit ................. 4.0-10.5 ribu/ul
Eritrosit ................. 3.40-5.50 juta/ul
Hematokrit ................. 35.00-50.00 vol%
Trombosit ................. 150-450 ribu/ul
RDW-CV ................. 11.5-14.7 %
MCV,MCH, MCHC
MCV ................. 80.0 – 97.00 fl
MCH ................. 27.0 – 32.0 pg
MCHC ................. 32.0 – 38.0 %
HITUNG JENIS
Gran% ................. 50.0 – 70.0 %
Limfosit% ................. 25.0 – 40.0 %
MID% ................. 4.0-11.0 %
Gran# ................. 2.50 – 7.00 ribu/ul
Limfosit# ................. 1.25-4.0 ribu/ul
MID# ................. ribu/ul
KIMIA DARAH
Glukosa Darah Sewaktu ................. <200 mg/dl
HATI
SGOT ................. 0-46 u/l
SGPT ................. 0-45 u/l
GINJAL
Ureum ................. 10-50 mg/dl
Kreatinin ................. 0.7-1.4 mg/dl
ELEKTROLIT
Natrium ................. 135-146 mmol/l
Kalium ................. 3.4-5.4 mmol/l
Chlorida ................. 95-100 mmol/l
ANALISIS DATA
Nama Klien : ..............................................
Umur : ..............................................
Ruangan/Kamar : ..............................................
No. Data Penyebab Masalah
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PRIORITAS MASALAH
Nama klien : ..............................................
Umur : ..............................................
Ruangan/kamar : ..............................................
No. RM : ..............................................
Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama Perawat)
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RENCANA KEPERAWATAN
Tujuan Dan
No. Diagnosa Keperawatan Intervensi Rasional
Kriteria Hasil
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IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN
No.
Waktu Waktu
Dx Implementasi TT Evaluasi TT
Tgl/jam Tgl/jam
Kep
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