ASUHAN KEPERAWATAN PADA PASIEN...................

DENGAN...............................................................................
DI RUANG ..............................................................
TANGGAL...................................................

I. IDENTITAS
A. Anak
1. Nama : .......................................................................................
2. Anak yang ke : .......................................................................................
3. Tanggal lahir/ umur : .......................................................................................
4. Jenis kelamin : .......................................................................................
5. Agama : .......................................................................................

B. Orang tua
1. Ayah
a. Nama : .......................................................................................
b. Umur : .......................................................................................
c. Pekerjaan : .......................................................................................
d. Pendidikan : .......................................................................................
e. Agama : .......................................................................................
f. Alamat : .......................................................................................
2. Ibu
a. Nama : .......................................................................................
b. Umur : .......................................................................................
c. Pekerjaan : .......................................................................................
d. Pendidikan : .......................................................................................
e. Agama : .......................................................................................
f. Alamat : .......................................................................................
II. GENOGRAM (dibuat bila ada hubungan dengan kasus yang dibuat)
III. ALASAN DIRAWAT
a) Keluhan Utama :
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b) Riwayat Penyakit :
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IV. RIWAYAT ANAK (0-6 TAHUN), tergantung penyakit

A. Perawatan dalam masa kandungan :
Dilakukan pemeriksaan kehamilan/tidak .................
 Berapa kali ..............................
Kapan :
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Tempat di ...................................................................
Kesan pemeriksaan tentang kehamilan ........................................................................
Obat-obat yang telah diminum .....................................................................................
Imunisasi ......................................................................................................................
Pemeriksaan lain ..........................................................................................................
Penyakit yang pernah diderita ibu ................................................................................
Penyakit dalam keluarga ..............................................................................................

B. Perawatan pada waktu kelahiran :

Umur kehamilan ........... dilahirkan di .........................................................................
Ditolong oleh.........................................
Berlangsungnya kehamilan (biasa/susah/dengan tindakan) .........................................
Lamanya proses persalinan ..........................................................................................
Keadaan bayi setelah lahir :
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BB lahir ..................... PBL ............... LK/LD ..........................................................

V. KEBUTUHAN BIO-PSIKO-SOSIAL-SPIRITUAL DALAM KEHIDUPAN SEHARI-

HARI
A. Bernafas
1. Kesulitan bernafas : ada/ tidak
2. Kesulitan dirasakan : menarik/mengeluarkan nafas
3. Keluhan yang di rasa : ...........................................................................................
4. Suara nafas : ..........................................................................................................
B. Makan dan minum
Bayi :
ASI/PASI :
(Berapa kali, pengenceran, sampai umur berapa, alasan)
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Makanan pendamping ASI : ........................................................................................
Makanan cair (air buah/sari buah) diberi umur ...........................................................
Bubur susu diberi umur ...............................................................................................
Nasi tim saring diberi umur..........................................................................................
Nasi tim diberi umur ....................................................................................................
Makanan tambahan lainnya.............. diberi umur .......................................................
Pola makan ...................................................... (berapa kali sehari/selang-seling ASI)

Anak-anak
Keadaan sebelum sakit (nafsu makan, berapa kali sehari, jenis makanan pokok, jenis
lauk, jenis sayuran, jenis buah, makanan pantang, kebiasaan makan termasuk cara
menyajikan makanan, jenis makanan selingan, kebiasaan jajan)
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Keaadan saat sakit bagaimana......................................................................................

C. Eliminasi (BAB/BAK)
Biasa memberitahu / tidak, melakukan sendiri/ditolong, tempat bab/bak, frekuensi,
warna, bau, konsistensi, kelainan
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D. Aktifitas
Permainan
Suka bermain (ya/tidak), permainan yang disukai .......................................................
Mainan yang dimiliki, teman bermain
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E. Rekreasi
Pernah / jarang / kadang-kadang, jenis rekreasi
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F. Istirahat dan tidur

Kebiasaan istirahat.
Kebiasaan tidur : (mencuci kaki sebelum tidur, kencing sebelum tidur, mengompol,
mengorok, mengigau, sering terjaga, kebiasaan tidur yang lain ada/tidak, tidur malam
mulai jam berapa, bangun pagi jam berapa, tidur sendiri/ditemani. Biasa tidur
siang/tidak, berapa jam ................................................................................................
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G. Kebersihan diri
Mandi :
Mandi sendiri/dibantu oleh ............................
Di ............................................
Memakai sabun/tidak ...................................................
Dikeringkan dengan handuk/tidak .................................
Gosok gigi : (dikerjakan sendiri/ditolong, menggunakan pasta gigi, waktu menggosok
gigi) ..............................................................................................................................
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H. Pengaturan suhu tubuh
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I. Rasa nyaman
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J. Rasa aman
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K. Belajar (anak dan orang tua)

Pengetahuan tentang makanan, sebab-sebab penyakit, kesehatan lingkungan, personal
hygiene, tumbuh kembang anak, pendidikan seks, keluarga berencana
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L. Prestasi
Kepandaian anak sekarang, prestasi yang dimiliki
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M. Hubungan sosial anak

Hubungan inter keluarga (orang yang dirasa paling dekat, orang yang dominan, orang
yang disegani, hubungan, komunikasi anak dan orang tua serta anggota keluarga lain)
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N. Melaksanakan ibadah (kebiasaan, bantuan yang diperlukan terutama saat anak sakit)
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VI. PENGAWASAN KESEHATAN

Bila sehat diawasi di tidak/ya di puskemas, dokter, dll ...................
Bila sakit minta pertolongan kepada ................................................
Kunjungan ke Posyandu
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Pengawasan anak dirumah
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Imunisasi (1-5 tahun)
Imunisasi Umur Tgl diberikan Reaksi Tempat
Imunisasi
BCG

DPT I, II, III

Polio

HB I, II, III

VII. PENYAKIT YANG PERNAH DIDERITA

No Jenis Akut/Kronis Umur Lamanya Pertolongan
Penyakit /Menular/tidak saat
sakit
VIII. KESEHATAN LINGKUNGAN
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IX. PERKEMBANGAN ANAK (0-6 tahun)

(Motorik kasar, motorik halus, bahasa, personal sosial)
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X. PEMERIKSAAN FISIK
A. Kesan umum (kebersihan, pergerakan, penampilan/postur/bentuk tubuh, termasuk
status gizi) ....................................................................................................................
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B. Warna kulit (pucat, normal, cyanosis, ikterus, kelainan) .............................................
C. Suara waktu menangis : ...............................................................................................
D. Tonus otot : ..................................................................................................................
E. Turgor kulit : ................................................................................................................
F. Udema : ada/ tidak, di ..................................................................................................
G. Kepala
Bentuk, keadaan rambut dan kulit kepala, UUB, adanya kelainan
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H. Mata
Bentuk bola mata, pergerakannya, keadaan pupil, konjungtiva, keadaan kornea mata,
sclera, bulu mata serta ketajaman penglihatan
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I. Hidung
Adanya secret, pergerakkan cuping hidung, adanya suara saat bernafas, gangguan lain
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J. Telinga
Kebersihan, keadaan alat pendengaran, kelainan
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K. Mulut
Kebersihan daerah sekitar mulut, keadaan selaput lendir, keadaan tenggorokan,
kelainan. Keadaan gigi (berlubang, karang gigi, kebersihan gigi, gusi, kerusakan lain)
keadaan lidah
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L. Leher
Pembesaran kelenjar/pembuluh darah, kaku kuduk, pergerakkan leher
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M. Thoraks
Bentuk dada, irama pernafasan, tarikan otot bantu pernafasan, adanya suara nafas
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N. Jantung : (bunyi, pembesaran)

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O. Persarafan : (reflek fisiologis, reflek patologis)

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P. Abdomen
Bentuk, pembesaran organ, keadaan pusat, teraba skibala, massa, nyeri pada perabaan,
distensia, hernia, peristaltic .........................................................................................
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Q. Ekstremitas
Kelainan bentuk, pergerakan, reflek lutut, adanya udem, keadaan unjung ekstremitas,
hal-hal lain
 Atas
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 Bawah
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R. Alat kelamin
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S. Anus
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T. Antopometri
1. BB = ........... kg
2. TB = .............. cm
3. Lingkar kepala = ........... cm
4. Lingkar dada = ..............cm
5. Lingkar lengan = ...........cm

U. Gejala kardinal
1. Suhu = ......... oC
2. Nadi =.................... kali/menit
3. Pernafasan = .......... kali/menit
4. Tekanan darah = .................. mmHg

XI. PEMERIKSAAN PENUNJANG

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XII. HASIL OBSERVASI

1. Interaksi anak/ bayi dengan orang tua
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2. Bentuk/arah komunikasi
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3. Ambivalensi/kontradiksi Prilaku
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4. Rasa aman anak/ bayi

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XIII. ANALISA DATA
Tgl/ Jam DATA FOKUS INTERPRETASI/ PENYEBAB MASALAH
XIV. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS
No Tgl. muncul Diagnosa Keperawatan Tgl. teratasi TTD
XV. RENCANA KEPERAWATAN
Nama/
No Tgl. Diagnosa keperawatan Tujuan & kriteria hasil Intervensi Rasional
TTD
 CATATAN PERKEMBANGAN
No. Nama/
No Tanggal Jam Implementasi Evaluasi
Dx TTD
 EVALUASI KEPERAWATAN
Hari/ Tgl/ No. Nama/
No EVALUASI
Jam DX TTD
LEMBAR PENGESAHAN

Mengetahui, Denpasar,.................
Pembimbing Praktik Mahasiswa

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NIP............................................. NIM.............................................

Mengetahui,
Pembimbing Akademik

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NIP....................................................