BAB IIIASUHAN KEPERAWATAN PADA ANAK

I. PENGKAJIANA. Data Demografi1. Klien/Pasienb. 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 Jawaba. Nama : ...b. Hubungan dengan klien: c. Suku: ...d. Agama: e. Alamat: ....................................f. No. telepon: .........

B. Riwayat Klien1. 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(lengkapi) Hepatitis B IBCG Hepatitis B IIHepatitis B III Polio IPolio II Polio IIIPolio IV DPT IDPT II DPT IIICampak 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 Keluarga1. Riwayat penyakit dalam keluarga: .......................................................... .......................................................................................................................................

2. Genogram

Keterangan gambar : : laki-laki: klien: perempuan: meninggal: tinggal dalam satu rumah

D. Riwayat Penyakit sekarang1. Penampilan umuma. Keadaan umum (kondisi klien secara umum): ................................................................................................................................................................................ .................................................................................................................................b. Pemeriksaaan Tanda-Tanda Vital1) 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 :..................cmb. Panjang badan/tinggi badan: ................cmc. Berat badan: .................kgd. Lingkar kepala : ................ cme. Lingkar dada: ................... cmf. Lingkar perut: ....................cm

g. Status nutrisi (z-score atau WHO, CDC): ........................................................................................................................................................................................ ..........................................................................................................................................................................................................................................................h. Kebutuhan kalori: ........................................................i. Jenis makanan: ...................................................................................Makanan yang disukai: ...................................................................................Alergi makanan : ..................................................................................j. 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 tidura. Lama waktu tidur (24 jam) : jamb. 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 keluargaa. 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 DATANODATAPROBLEMETIOLOGI

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11. RENCANA KEPERAWATANNOTGL/JAMDX KEPINTERVENSI

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12. IMPLEMENTASI

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13. EVALUASI (perkembangan setiap hari dalam bentuk SOAP)

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