ASUHAN KEPERAWATAN

ANAK ………………............DENGAN...........................................................
DI RUANG ……………………….
RSUD …………………………………………………………………………………………

DISUSUN OLEH:

NAMA : ..............................................
NIM : ..............................................
KELAS : ..............................................

YAYASAN BANJAR INSAN PRESTASI

SEKOLAH TINGGI ILMU KESEHATAN INTAN MARTAPURA
TAHUN AKADEMIK 2021/2022
 LEMBAR PENGESAHAN

NAMA : .................................................................................................................
NIM : .................................................................................................................
SEMESTER : .................................................................................................................
JUDUL : ASUHAN KEPERAWATAN ANAK ....... DENGAN .........................
..........................................................DI RUANG ……................................................................
RSUD............................................................................................................................................

Mengetahui,

Pembimbing Wahana Praktik Dosen Pembimbing

(............................................................) (............................................................)
NIP. NIK.
 ASUHAN KEPERAWATAN ANAK

Tanggal pengkajian : ......................................................................................

Diagnosis Medis : ....................................................................................

I. Identitas Pasien dan Orang Tua

A. Identitas Pasien
Nama Anak : .........................................................................................
Tempat, tanggal lahir : .........................................................................................
Jenis kelamin : .........................................................................................
Usia : .........................................................................................
Pendidikan : .........................................................................................
B. Identitas Orang tua
Ibu Ayah Wali
Nama : ............................ ............................ ............................
Usia : ............................ ............................ ............................
Pendidikan : ............................ ............................ ............................
Pekerjaan : ............................ ............................ ............................
Agama : ............................ ............................ ............................
Suku Bangsa : ............................ ............................ ............................
Alamat Rumah : ............................ ............................ ............................
............................ ............................ ............................
Pemberi Informasi : ............................ ............................ ............................

Genogram Keluarga
II. Keluhan utama : ......................................................................................................
.....................................................................................................
....................................................................................................
III. Keadaan Sakit Saat Ini
Penyakit saat ini : ..............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
IV. Riwayat kesehatan masa lalu :
A. Riwayat kelahiran dan persalinan ibu :
1. Prenatal care
a. Riwayat kunjungan prenatal : .......................Kali
b. Riwayat periksa kehamilan : Dokter Bidan
Perawat lain-lain
c. Golongan darah/ Resus ibu : …………..........
Golongan darah/Resus ayah :…………...........
d. Usia Ibu saat kehamilan anak yang sakit : .......................................
e. Riwayat penyakit selama kehamilan : ...................................................
f. Obat-obat yang digunakan : ...................................................
2. Natal
a. Gestasi : Aterm Prematur Postmatur
b. Tipe persalinan : Pervaginam Operasi Dengan Bantuan
c. Tempat melahirkan : ..........................................................................
d. Komplikasi persalinan : .........................................................................
3. Post natal
a. Kondisi bayi saat lahir : menangis/tidak.......................................
…………………………………………
…………………………………………
b. Komplikasi bayi saat lahir : …………………………………………
…………………………………………
…………………………………………
…………………………………………
B. Riwayat Penyakit sebelumnya
1. Penyakit yang pernah diderita : ……………….....Pada umur : ………
2. Pernah dirawat di rumah sakit : Ya Tidak
3. Riwayat Operasi : ……………………………………....
4. Riwayat kecelakaan : ………………………………………
5. Obat-obatan yang digunakan : ……………………………………
6. Alergi : Ya Tidak
 C. Imunisasi
No Jenis imunisasi Waktu pemberian Frekuensi Reaksi setelah pemberian
1 BCG
2 DPT (I,II,III)
3 Polio (I,II,III,IV)
4 Campak
5 Hepatitis

V. Riwayat sosial
1. Pengasuh anak : ...............................................................
2. Hubungan dengan anggota keluarga : ...............................................................
3. Hubungan dengan teman sebaya : ...............................................................
4. Lingkungan rumah : ..............................................................

VI. Pengkajian keperawatan

1. Keadaan umum : .........................................................................................
2. Tingkat kesadaran : .......................................................................................
3. Tanda-tanda vital
a. Tekanan darah : ..................................... mmHg
b. Denyut nadi : ............... x / menit, irama : .................................
c. Suhu : .......... o C; Tempat Pengukuran : ......................
d. Pernapasan :............ x/ menit, Irama : .....................................
e. Nyeri : P : ........................................................................
Q : .......................................................................
R : .......................................................................
S : .......................................................................
T : .......................................................................
4. Sistem Respiratori
a. Bernafas
1) Retraksi dinding dada : ...............................................................
2) Pernafasan cuping hidung : ..............................................................
3) Posisi yang nyaman : ..............................................................
b. Toraks
1) Bentuk nafas : ....................................................................................
2) Bunyi dada : .....................................................................................
5. Status Nutrisi
No Kondisi Sebelum sakit Saat sakit
1 Jenis makanan
2 Frekuensi makan
3 Nafsu makan
4 Berat badan
5 Tinggi badan
6 Lingkar kepala
7 Lingkar lengan atas
8 Status Gizi

6. Sistem Gastroentestinal
1) Nyeri : Ada/Tidak ada* Lokasi nyeri : .........................................
2) Kekakuan : Ada/Tidak ada* Lokasi : ..................................................
3) Bising usus : ............x/menit
4) Kram : Ada/Tidak ada* Lokasi : .................................................
5) Mual : Ada/Tidak ada*
6) Muntah : Frekuensi............Jumlah..........Karakteristik.....................

7. Status Hidrasi
No Kondisi Sebelum Sakit Saat Sakit
1 Jenis minuman*
2 Jumlah air yang diminum
3 Cara pemenuhan
4 Status turgor kulit
5 Perdarahan
6 Kebutuhan Cairan
*ASI atau Sufor pada bayi

a. Sistem Renal
1) Fungsi ginjal
a) Disuria : Ada/Tidak Ada*
b) Nyeri : Ada/Tidak Ada* Lokasi Nyeri ..........................................
c) Ascites : Ada/Tidak Ada*
d) Edema : Ada/Tidak Ada* Lokasi
2) Karakteristik urine
a) Warna :....................................................................................................
b) Bau : ...................................................................................................
c) Menangis setelah berkemih :..................................................................
8. Eliminasi (BAB & BAK)
No Kondisi Sebelum Sakit Saat Sakit
1 BAB
a. Frekuensi
b. Konsistensi
c. Penggunaan obat pencahar
2 BAK
a. Frekuensi
b. Warna
c. Jumlah
d. Kesulitan saat berkemih

9. Sistem Sirkulasi dan Hematologik

a. Suara jantung :..............................................................................
b. Capilary Refill Time : .............................................................................
c. Irama jantung :............................................................................
d. Ptekie : Ada/Tidak Ada* Lokasi ......................................
e. Memar : Ada/Tidak Ada* Lokasi ....................................
f. Perdarahan dari membrane mukosa/dari luka suntikan atau fungsi vena :......
g. Pembesaran hati : .............................................................................
h. Pembesaran limpa : .............................................................................

10. Istirahat tidur

No Kondisi Sebelum Sakit Saat Sakit
1 Waktu tidur
2 Pola tidur
3 Kebiasaan sebelum tidur
4 Kebiasaan terbangun
5 Kualitas tidur
6 Kedalaman tidur

11. Pola aktivitas latihan

a. Aktivitas bermain
No Kondisi Sebelum Sakit Saat Sakit
1 Jenis permainan
2 Kesulitan saat bermain
3 Kekakuan saat bermain
4 Pengalaman hospitalisasi
b. Sistem muskuloskeletal
1) Ukuran otot : Normal/Atrofi/Hipertrofi*
2) Tonus otot : ...................................................................................
3) Kekuatan : ...................................................................................
4) Gerakan abnormal : Ada/Tidak Ada* Berupa ......................................
5) Kontrol postur
a) Mempertahankan posisi tegak : Mampu/Tidak Mampu*
b) Bergoyang-goyang : Mampu/Tidak Mampu*
6) Persendian
a) Rentang gerak : ..................................................................................
b) Kontraktur : Ada/Tidak Ada* Lokasi ...........................................
c) Nyeri : Ada/Tidak Ada* Lokasi ............................................
d) Tonjolan abnormal : Ada/Tidak Ada* Lokasi ....................................

7) Tulang Belakang
a) Bentuk : Normal Lordosis Kifosis Skoliosis
b) Kelainan : .................................................................................

12. Sistem Integumen

No Kondisi Sebelum Sakit Saat Sakit
1 Warna Kulit
2 Luka
3 Jenis Luka
4 Penyebab Luka
5 Letak Luka
6 Jenis Perawatan Luka
7 Frekuensi Perawatan Luka
8 Kelainan pada Kulit

13. Sistem Neurologis

a. Pemeriksaan kepala
1) Bentuk kepala : ........................................................................................
2) Fontanel : ........................................................................................
3) Lingkar kepala (dibawah 2 tahun) : ...................................................
4) Kelainan : Mikrosefalus Makrosefalus
5) Sakit Kepala : Ya/Tidak*
b. Reaksi pupil
Reaksi terhadap cahaya : .........................................................................
 c. Aktivitas kejang
1) Jenis : ....................................................................................
2) Lamanya : .....................................................................................
d. Fungsi persepsi sensoris
1) Mata : …………………………………………………….......
2) Telinga : …………………………………………………….......
3) Hidung : …………………………………………………………
4) Lidah : …………………………………………………………
…………………………………………………………
5) Reaksi terhadap nyeri : ............................................................................
............................................................................
............................................................................
14. Seksual Reproduksi dan Sistem Genitalia
a. Penis
1) Scrotum : …………………………………………………………
2) Testis : …………………………………………………………
b. Vagina
1) Sekret : …………………………………………………………
2) Mons Pubis : …………………………………………………………
3) Labium Mayora/Minora : …………………………………………
c. Anus/ Perianal
1) Iritasi : ............................................................................................
2) Kelainan : ............................................................................................
15. Sistem endokrin
a. Status hidrasi
1) Poliuria : Ya/Tidak*
2) Polifagia : Ya/Tidak*
3) Polidpsi : Ya/Tidak*
b. Tampilan umum
1) Iritabilitas : Ya/Tidak*
2) Tremor : Ya/Tidak*
c. Kelainan Pertumbuhan : Kretinisme Gigantisme
16. Pemeriksaan Laboratorium
Tanggal Pemeriksaan :................................................................................
No Jenis Pemeriksaan Nilai Normal Hasil

17. Pemeriksaan Penunjang

.................................................................................................................................
.................................................................................................................................
18. Obat-obatan
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
19. Ringkasan Riwayat Kesehatan
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

....................... ........................2022
Mahasiswa,

(....................................................)
A. DIAGNOSIS KEPERAWATAN
1. ANALISIS DATA

Data Etiologi Masalah

2. DAFTAR PRIORITAS DIAGNOSIS KEPERAWATAN

a. .....................................................................................................................................
.....................................................................................................................................
b. .....................................................................................................................................
.....................................................................................................................................
c. .....................................................................................................................................
.....................................................................................................................................
d. .....................................................................................................................................
.....................................................................................................................................
B. RENCANA KEPERAWATAN
DIAGNOSIS TUJUAN
NO. RENCANA INTERVENSI
KEPERAWATAN TUJUAN KRITERIA HASIL
C. IMPLEMENTASI & EVALUASI
Hari, Tanggal
No Implementasi Evaluasi Paraf
Waktu
 ASUHAN KEPERAWATAN BAYI

Tanggal pengkajian : ..................................................................................................

Diagnosis Medis : ..................................................................................................

DATA PERSONAL
1. Nama : ................................................................................................
2. Alamat : ................................................................................................
3. Tempat, tanggal lahir : ...............................................................................................
4. Jenis kelamin : ...............................................................................................
5. Agama : ...............................................................................................
6. Usia Bayi : ...............................................................................................
7. Nama Penanggung Jawab : ...................................................................................
8. Hubungan dengan Pasien : ..................................................................................
9. Alamat Penanggung jawab : .................................................................................
Keluhan Utama:
...........................................................................................................................................
...........................................................................................................................................
Riwayat Penyakit Saat Ini:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Genogram Keluarga
A. Riwayat kelahiran :
1. Perawatan Prenatal
a. Riwayat terkena radiasi : ..................................................................................
b. Golongan darah ibu: ……………Golongan darah ayah: ………………….....
2. Natal
a. Jenis persalinan: ………………………………………………………………
b. Komplikasi persalinan: ……………………………………………………….
3. Post Natal
a. Kondisi bayi: …………………………………………………………………
b. APGAR Score: ………………………………………………………………

B. Riwayat Penyakit, Cedera, dan Operasi

1. Klien pernah mengalami penyakit: …………………………………………………
2. Riwayat konsumsi obat : …………………………………………………………….
3. Riwayat kecelakaan: ………………………………………………………………..
4. Riwayat operasi : ……………………………………………………………………

C. Riwayat Alergi
Jenis Alergen: ……………………………………………………………………………

D. Riwayat Imunisasi
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………

E. Perkembangan Bayi
1. Motorik Kasar : …………………………………………………………
2. Motorik Halus : …………………………………………………………
3. Bicara dan Bahasa : …………………………………………………
4. Sosialisasi dan Kemandirian : …………………………………………………………
F. KONSERVASI ENERGI
1. Tanda–tanda vital:
a. Tekanan darah : …………………………………………………………
b. Denyut nadi : ........................................irama: .....................................
c. Suhu : .......................................Tempat Pengukuran: ………..
d. Pernapasan : ..................................... Irama: ......................................
e. Saturasi oksigen : ....................................
2. Nutrisi/Cairan
Kondisi Hasil Pengkajian

1. Jenis Makanan ........................................................................................

2. Berat Badan ........................................................................................
3. Panjang Badan ........................................................................................
4. Lingkar Lengan Atas ........................................................................................
5. Lingkar perut ........................................................................................

3. Cairan
Kondisi Hasil Pengkajian

1. Jenis cairan yang diberikan ........................................................................................

2. Volume cairan ........................................................................................
3. Cara pemenuhan ........................................................................................
4. Status turgor kulit ........................................................................................
5. Perdarahan ........................................................................................

4. Eliminasi (BAB & BAK)

Kondisi Hasil Pengkajian
BAB
1. Saluran BAB ........................................................................................
2. Frekuensi ........................................................................................
3. Konsistensi ........................................................................................
 Kondisi Hasil Pengkajian
4. Karekteristik feses ........................................................................................
5. Obat pencahar ........................................................................................
BAK
1. Frekuensi ........................................................................................
2. Jumlah Urine (24 jam) ........................................................................................
3. Warna Urine ........................................................................................
4. Nyeri selama BAK ........................................................................................
5. Terpasang kateter urine ........................................................................................

5. Istirahat tidur
Kondisi Hasil Pengkajian

1. Waktu tidur ........................................................................................

2. Pola tidur ........................................................................................

6. Integumen
Kondisi Hasil Pengkajian

1. Warna kulit ........................................................................................

2. Luka ........................................................................................
3. Jenis Luka ........................................................................................
4. Penyebab Luka ........................................................................................
5. Grade luka ........................................................................................
6. Letak luka ........................................................................................
7. Jenis Perawatan Luka ........................................................................................
8. Frekuensi Perawatan Luka ........................................................................................
 G. INTEGRITAS STRUKTURAL
1. Keadaan umum : .................................................................................................................
2. Kesadaran : .................................................................................................................
3. Sistem Respiratori
a. Bernapas
1) Retraksi : ...................................................................................
2) Pernapasan cuping hidung : ...................................................................................
3) Posisi yang nyaman : ...................................................................................
b. Thorak
1) Bunyi napas : ...................................................................................
2) Bentuk dada : ...................................................................................
c. Alat bantu napas : ...................................................................................
4. Sistem Sirkulasi
a. Suara jantung : .....................................................................................................
b. Capilary Refill Time : .....................................................................................................
c. Irama jantung : .....................................................................................................
5. Sistem Neurologik
a. Pemeriksaan kepala
1) Bentuk kepala : ........................................................................................................
2) Fontanel : ........................................................................................................
b. Reaksi pupil
Reaksi terhadap cahaya : ................................................................................................
c. Aktivitas kejang
1) Jenis : ...........................................................................................................
2) Lamanya : ...........................................................................................................
d. Fungsi sensoris
Reaksi terhadap nyeri : ............................................................................................
6. Sistem Gastrointestinal
1) Nyeri : ............................................................................................
2) Ketegangan : ............................................................................................
3) Bising usus : ............................................................................................
4) Muntah : ............................................................................................
7. Sistem Renal
Fungsi ginjal
a. Nyeri : ........................................................................................................
b. Acites : ........................................................................................................
c. Edema : ........................................................................................................
8. Genitalia
a. Jenis kelamin : ........................................................................................................
b. Kebersihan : .......................................................................................................
c. Iritasi : ........................................................................................................
d. Sekret : ........................................................................................................
9. Pengkajian Muskuloskletal
a. Fungsi motorik kasar
1) Ukuran otot : ...................................................................................................
2) Tonus otot : ...................................................................................................
3) Gerakan abnormal : ...................................................................................................
b. Fungsi motorik halus
Menggenggam jari tangan : ...........................................................................................
c. Tulang Belakang
Bentuk : ...................................................................................................
10. Sistem Hematologik
a. Kulit
1) Warna : ................................................................................................
2) Ptekie : ..................................................................................................
3) Memar : ..................................................................................................
4) Perdarahan dari membran mukosa atau dari luka suntikan atau fungsi vena : …….
b. Abdomen
1) Pembesaran hati : ..................................................................................................
2) Pembesaran limpa : ..................................................................................................
PEMERIKSAAN PENUNJANG
1. Hasil Laboratorium Darah
Tanggal:
Jenis Pemeriksaan Hasil Nilai Normal

2. Pemeriksaan Penunjang
.........................................................................................................................................
.........................................................................................................................................
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3. Terapi Medis Yang Diperoleh

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RINGKASAN RIWAYAT KESEHATAN
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....................... ........................2022
Mahasiswa,

(....................................................)
B. DIAGNOSIS KEPERAWATAN
1. ANALISIS DATA
Data Etiologi Masalah
 2. DAFTAR PRIORITAS DIAGNOSIS KEPERAWATAN

a. .....................................................................................................................................
.....................................................................................................................................
b. .....................................................................................................................................
.....................................................................................................................................
c. .....................................................................................................................................
.....................................................................................................................................
d. .....................................................................................................................................
.....................................................................................................................................
 C. RENCANA KEPERAWATAN
DIAGNOSIS TUJUAN
NO. RENCANA INTERVENSI
KEPERAWATAN TUJUAN KRITERIA HASIL
D. IMPLEMENTASI & EVALUASI
Hari, Tanggal
No Implementasi Evaluasi Paraf
Waktu
 LAPORAN PASIEN RESUME

A. DATA PERSONAL
1. Nama : .....................................................................................................
2. Alamat : .....................................................................................................
3. Tempat, tanggal lahir : .....................................................................................................
4. Jenis kelamin : .....................................................................................................
5. Agama : .....................................................................................................
6. Usia : .....................................................................................................
7. Alamat : .....................................................................................................

B. DATA PASIEN SINGKAT

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C. DATA FOKUS
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D. DIAGNOSIS KEPERAWATAN
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E. INTERVENSI KEPERAWATAN
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F. IMPLEMENTASI KEPERAWATAN
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G. EVALUASI KEPERAWATAN
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....................... ........................2022
Mahasiswa,

(....................................................)