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Giaful Muharam STIKes Karsa Husada Garut
I. Biodata
A. Identitas Klien
Nama / Nama Panggilan : ...........................................................................................
Tempat tgl lahir : ...........................................................................................
Jenis kelamin : ...........................................................................................
Agama : ...........................................................................................
Pendidikan : ...........................................................................................
Alamat : ...........................................................................................
Tgl Masuk : ...........................................................................................
Tgl Pengkajian : ...........................................................................................
Diagnosa Medik : ...........................................................................................
Rencana Terapi : ...........................................................................................
B. Identitas Orang Tua
Ayah
Nama : ...........................................................................................
Usia : ...........................................................................................
Pendidikan : ...........................................................................................
Pekerjaan : ...........................................................................................
Agama : ...........................................................................................
Alamat : ...........................................................................................
Ibu
Nama : ...........................................................................................
Usia : ...........................................................................................
Pendidikan : ...........................................................................................
Pekerjaan : ...........................................................................................
Agama : ...........................................................................................
Alamat : ...........................................................................................
Giaful Muharam STIKes Karsa Husada Garut
C. Identitas Saudara Kandung
NO Nama Usia Hubungan Status Kesehatan
II. Riwayat Kesehatan
A. Riwayat Kesehatan Kesehatan Sekarang
Keluhan Utama : ...............................................................................................................
Riwayat Keluhan Utama :
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............................................................................................................................................
Keluhan Pada Saat Pengkajian
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B. Riwayat Kesehatan Lalu ( Khusus untuk anak usia 0-5 tahun )
1. Prenatal Care
a. Ibu memeriksakan kehamilannya setiap minggu di ...............................................
Keluhan selama hamil yang dirasakan oleh ibu, tapi oleh dokter dianjurkan
untuk .......................................................................................................................
b. Riwayat terkena radiasi : ........................................................................................
c. Riwayat berat badan selama hamil : .......................................................................
d. Riwayat Imunisasai TT : ........................................................................................
e. Golongan darah ibu : ................. Golongan darah ayah : .....................................
Giaful Muharam STIKes Karsa Husada Garut
2. Natal
a. Tempat melahirkan : ..........................................................................................
b. Jenis persalinan : ..........................................................................................
c. Penolong persalinan : ..........................................................................................
d. Komplikasi yang dialami oleh ibu pada saat melahirkan dan setelah melahirkan :
................................................................................................................................
3. Post Natal
a. Kondisi Bayi : .................................. APGAR : ..................................................
b. Anak pada saat lahir tidak mengalami : ................................................................
( untuk semua usia )
o Klien pernah mengalami penyakit : ............................... pada umur : ...................
diberikan obat oleh : ...............................................................................................
o Riwayat kecelakaan : ..............................................................................................
o Riwayat mengkonsumsi obat-obatan berbahaya tanpa anjuran dokter dan
menggunakan zat / substansi kimia yang berbahaya : ............................................
o Perkembangan anak dibanding saudara –saudaranya :
.................................................................................................................................
Giaful Muharam STIKes Karsa Husada Garut
C. Riwayat Kesehatan Keluarga
o Genogram
Giaful Muharam STIKes Karsa Husada Garut
III. Riwayat Imunisasi ( Imunisasi lengkap )
No Jenis Imunisasi Waktu Pemberian Frekuensi Reaksi Setelah Pemberian Frekuensi
1 BCG
2 DPT (I,II,III)
3 Polio (I,II,III,IV)
4 Campak
5 HEpatitis
IV. Riwayat Tumbuh Kembang
A. Pertumbuhan Fisik
1. Berat Badan : ........................ Kg
2. Tinggi Badan : ........................ Cm
3. Waktu tumbuh gigi ................................. gigi tanggal .................................
Jumlah gigi ............................. buah
B. Perkembangan tiap tahap
Usia anak saat
1. Berguling : ................................ Bulan
2. Duduk : ................................ Bulan
3. Merangkak : ................................ Bulan
4. Berdiri : ................................ Bulan
5. Berjalan : ................................ Bulan
6. Senyum kepada orang lain pertama kali : ..................... tahun
7. Bicara pertama kali : ......................... tahun, dengan menyebutkan: ..........................
8. Berpakaian tanpa bantuan : .........................................................................................
V. Riwayat Nutrisi
A. Pemberian ASI
............................................................................................................................................
B. Pemberian susu formula
1. Alasan Pemberian : ...........................................................................................
2. Jumlah pemberian : ...........................................................................................
3. Cara pemberian : ...........................................................................................
Giaful Muharam STIKes Karsa Husada Garut
Pola perubahan nutrisi tiap tahap usia sampai nutrisi saat ini
Usia Jenis Nutrisi Lama Pemberian
VI. Riwayat Psikososial
o Anak tinggal bersama : ........................................ di : ............................................
o Lingkungan berada di : ...........................................................................................
o Rumah dekat dengan : .................................. tempat bermain :.............................
Kamar Klien : ...................................................................................................................
o Rumah ada tangga : ...........................................................................................
o Hubungan antar keluarga : ...........................................................................................
o Pengasuh anak : ...........................................................................................
VII. Riwayat Spiritual
o Support sistem dalam keluarga : ...............................................................................
o Kegiatan keagamaan : ...............................................................................
VIII. Reaksi hospitalisasi
A. Pengalaman keluarga tentang sakit dan rawat inap
o Ibu membawa anaknya ke RS karena :
...................................................................................................................................
o Apakah dokter menceritakan tentang kondisi anak :
...................................................................................................................................
o Perasaaan orang tua saat ini :
...................................................................................................................................
o Orang tua selalu berkunjung ke RS :
...................................................................................................................................
Giaful Muharam STIKes Karsa Husada Garut
o Yang akan tinggal dengan anak :
...................................................................................................................................
B. Pemahaman anak tentang sakit dan rawat inap
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
IX. Aktivitas Sehari – hari
A. Nutrisi
Konsisi Sebelum Sakit Saat Sakit
Selera Makan
B. Cairan
Konsisi Sebelum Sakit Saat Sakit
1. Jenis Minuman
2. Frekuensi Minum
3. Kebutuhan Cairan
4. Cara Pemenuhan
C. Eliminasi ( BAB & BAK )
Konsisi Sebelum Sakit Saat Sakit
BAK
1. Tempat pembuangan
2. Frekuensi (waktu)
3. Konsistensi
4. Kesulitan
5. Obat Pencahar
BAB
1. Tempat pembuangan
2. Frekuensi (waktu)
3. konsistensi
4. Kesulitan
5. Obat pencahar
Giaful Muharam STIKes Karsa Husada Garut
D. Istirahat Tidur
Konsisi Sebelum Sakit Saat Sakit
1. Jam Tidur
- Siang
- Malam
2. Pola tidur
3. Kebiasaan sebelum
tidur
4. Kesulitan tidur
E. Olah Raga
Konsisi Sebelum Sakit Saat Sakit
1. Program Olah raga
2. Jenis dan frekuensi
3. Kondisi setelah Olah
raga
F. Personal Hygiene
Konsisi Sebelum Sakit Saat Sakit
1. Mandi
- Cara
- Frekuensi
- Alat mandi
2. Cuci rambut
- Frekuensi
- Cara
3. Gunting kuku
- Frekuensi
- Cara
4. Gosok gigi
- Frekuensi
- Cara
Giaful Muharam STIKes Karsa Husada Garut
G. Aktivitas / Mobilitas Fisik
Konsisi Sebelum Sakit Saat Sakit
1. Kegiatan sehari – hari
2. Pengaturan jadwal
harian
3. Pengaturan alat bantu
aktivitas
4. Kesulitan pergerakan
tubuh
H. Rekreasi
Konsisi Sebelum Sakit Saat Sakit
1. Perasaan saat sekolah
2. Waktu luang
3. Perasaan setelah
rekreasi
4. Waktu senggang
keluarga
5. Kegiatan hari libur
Giaful Muharam STIKes Karsa Husada Garut
X. Pemeriksaan Fisik
Keadaan umum : ......................................................................................................
Kesadaran : ......................................................................................................
TTV
- TD : ......................................................................................................
- N : ......................................................................................................
- R : ......................................................................................................
- S : ......................................................................................................
Berat badan : ......................................................................................................
Tinggi badan : ......................................................................................................
Kepala
Inspeksi
Keadaan rambut & hygiene kepala : ...............................................................................
Warna rambut : ...............................................................................
Penyebaran : ...............................................................................
Mudah rontok : ...............................................................................
Kebersihan rambut : ...............................................................................
Palpasi
Benjolan : ...............................................................................
Nyeri tekan : ...............................................................................
Tekstur rambut : ...............................................................................
Muka
Inspeksi
Kesimetrisan : ...............................................................................
Bentuk wajah : ...............................................................................
Gerakan abnormal : ...............................................................................
Ekspreai wajah : ...............................................................................
Giaful Muharam STIKes Karsa Husada Garut
Palpasi
Nyeri tekan : ...............................................................................
Data lain : ...............................................................................
Mata
Inspeksi
Pelpebra : ...............................................................................
Sclera : ...............................................................................
Conjungtiva : ...............................................................................
Pupil : ...............................................................................
Posisi mata : ...............................................................................
Gerakan bola mata : ...............................................................................
Penutupan kelopak mata : ...............................................................................
Keadaan bulu mata : ...............................................................................
Keadaan visus : ...............................................................................
Penglihatan : ...............................................................................
Palpasi
Tekanan bola mata : ...............................................................................
Data lain : ...............................................................................
Hidung & Sinus
Inspeksi
Posisi hidung : ...............................................................................
Bentuk hidung : ...............................................................................
Keadaan septum : ...............................................................................
Secret / cairan : ...............................................................................
Giaful Muharam STIKes Karsa Husada Garut
Data lain : ...............................................................................
Telinga
Inspeksi
Posisi telinga
Ukuran / bentuk telinga : ...............................................................................
Aurikel : ...............................................................................
Lubang telinga : ...............................................................................
Pemakaian alat bantu : ...............................................................................
Palpasi
Nyeri tekan : ...............................................................................
Pemeriksaan uji pendengaran
- Rine : ...............................................................................
- Weber : ...............................................................................
- Swabach : ...............................................................................
Pemeriksaan vestibuler : ...............................................................................
Data lain : ...............................................................................
Mulut
Inspeksi
Gigi
- Keadaan gigi : ...............................................................................
- Karang gigi / caries : ...............................................................................
- Pemakaian gigi palsu : ...............................................................................
Giaful Muharam STIKes Karsa Husada Garut
Gusi : ...............................................................................
Lidah : ...............................................................................
Bibir
- Cianosis / pucat / tidak : ...............................................................................
- Basah / kering / pecah : ...............................................................................
- Mulut berbau / tidak : ...............................................................................
- Kemampuan bicara : ...............................................................................
Data lain : ...............................................................................
Tenggorokan
Warna mukosa : ...............................................................................
Nyeri tekan : ...............................................................................
Nyeri menelan : ...............................................................................
Leher
Inspeksi
Kelenjar tyroid : ...............................................................................
Palpasi
Kelenjar tyroid : ...............................................................................
Kaku kuduk : ...............................................................................
Kelenjar limfe : ...............................................................................
Data lain : ...............................................................................
Thorax dan Pernafasan
Inspeksi
Bentuk dada : ...............................................................................
Irama pernafasan : ...............................................................................
Pengembangan : ...............................................................................
Tipe pernafasan : ...............................................................................
Data lain : ...............................................................................
Palpasi
Vokal fremitus : ...............................................................................
Massa / nyeri : ...............................................................................
Auskultasi
Giaful Muharam STIKes Karsa Husada Garut
Suara nafas : ...............................................................................
Suara tambahan : ...............................................................................
Perkusi
Suara : ...............................................................................
Data lain : ...............................................................................
Jantung
Palpasi
Ictus kordis : ...............................................................................
Perkusi
Pembesaran jantung : ...............................................................................
Auskultasi
Bunyi jantung : ...............................................................................
Data lain : ...............................................................................
Abdomen
Inspeksi
Membuncit : ...............................................................................
Ada luka / tidak : ...............................................................................
Palpasi
Hepar : ...............................................................................
Lien : ...............................................................................
Nyeri tekan : ...............................................................................
Auskultasi
Peristaltik / bising usus : ...............................................................................
Perkusi
Tympani : ...............................................................................
Redup : ...............................................................................
Data lain : ...............................................................................
Genetalia dan anus
Keadaan : ...............................................................................
Keluhan : ...............................................................................
Giaful Muharam STIKes Karsa Husada Garut
Ekstremitas atas dan bawah
Ekstremitas Atas
a. Motorik
- Pergerakan Kanan / kiri : ...............................................................................
- Pergerakan abnormal : ...............................................................................
- Kekuatan otot : ...............................................................................
- Tonus otot : .....................................................................
- Koordinasi gerak : ...............................................................................
b. Reflek
- Biceps kanan / kiri : ...............................................................................
- Triceps kanan / kiri : ...............................................................................
c. Sensori
- Nyeri : ...............................................................................
- Rangsang sushu : ...............................................................................
- Rasa raba : ...............................................................................
Ekstremitas Bawah
a. Motorik
- Gaya berjalan : ...............................................................................
- Kekuatan kanan / kiri : ...............................................................................
- Tonus otot kanan / kiri : ...............................................................................
b. Refleks
- KPR kanan / kiri : ...............................................................................
- APR kanan / kiri : ...............................................................................
- Babinsky kanan / kiri : ...............................................................................
c. Sensori
- Nyeri : ...............................................................................
- Rangsang sushu : ...............................................................................
- Rasa raba : ...............................................................................
Data lain : ...............................................................................
Giaful Muharam STIKes Karsa Husada Garut
Status Neurologi
Saraf – saraf cranial
a. Nervus I ( Olfactorus ) Penghindu : ...............................................................................
b. Nervus II ( Opticus ) penglihatan : ...............................................................................
c. Nervus III, IV, VI ( Oculomotorius, Troclearis, Abdusens )
- Konstriksi pupil : ...............................................................................
- Gerakan kelopak mata : ...............................................................................
- Pergerakan bola mata : ...............................................................................
- Gerakan mata ke atas & bawah : ...............................................................................
d. Nervus V ( Trigeminus )
- Sensibilitas : ...............................................................................
- Refleks dagu : ...............................................................................
- Refleks Kornea : ...............................................................................
e. Nervus VII ( Facialis )
- Gerakan mimik : ...............................................................................
- Pengecapan 2/3 lidah depan : ...............................................................................
f. Nervus VIII ( Acusticus )
- Fungsi pendengaran : ...............................................................................
g. Nervus IX dan X ( Glospharingeus dan Vagus )
- Reflek menelan : ...............................................................................
- Refleks muntah : ...............................................................................
- Pengecapan 1/3 lidah belakang : ...............................................................................
- Suara : ...............................................................................
h. Nervus XI ( Assesorius )
- Memalingkan kepala ke kiri dan kanan :.....................................................................
- Mengangkat bahu : ...............................................................................
i. Nervus XII ( Hypoglossus )
- Deviasi Lidah : ...............................................................................
Tanda – tanda perangsangan selaput otak
a. Kaku kuduk : ...............................................................................
b. Kernig sign : ...............................................................................
c. Refleks Brudzinski : ...............................................................................
Giaful Muharam STIKes Karsa Husada Garut
d. Fefleks Lasegu : ...............................................................................
Data lain : ...............................................................................
XI. Pemeriksaan tingkat perkembangan ( 0-6 tahun )
Dengan Menggunakan DDST
1. Motorik kasar
2. Motorik halus
3. Bahasa
4. Personal social
Giaful Muharam STIKes Karsa Husada Garut
XII. Test Diagnostik
No Nama Test Hasil Unit Nilai Normal
1 Hematologi
Darah Rutin
Hemoglobin g/dL 13.0-18.0
Hematokrit % 40-52
Leukosit /mm3 3.800-10.000
Trombosit /mm3 150.000-440.000
Eritrosit juta/mm3 3.5-6.5
Laju Endap Darah /mm3
Morfologi darah tepi
Eritrosit
Leukosit
Trombosit
Kesan
2 Kimia Klinik
AST/SGOT u/L s/d 37
ALT/SGPT u/L 40
Ureum Mg/dL 15-50
Kreatinin Mg/dL 15-50
Protein total Mg/dL 0.7-1.2
Albumin Mg/dL 6.6-8.7
Glukosa sewaktu Mg/dL 3.5-5
Glukosa puasa Mg/dL <140
Kolesterol total Mg/dL 70-110
Natrium Mg/dL 135-145
Kalium Mg/dL 3.6-5.5
3 Imunologi
HbsAg
Anti Dengue Igg
Anti Dengue IgM
Widal
4 Lainnya
XIII. Terapi saat Ini
Giaful Muharam STIKes Karsa Husada Garut
ANALISA DATA
No Data Etiologi Problem
Giaful Muharam STIKes Karsa Husada Garut
DIAGNOSA KEPERAWATAN
1.
2.
3.
4.
5.
Giaful Muharam STIKes Karsa Husada Garut
NURSING CARE PLAN
Diagnosa Keperawatan/ Masalah
Kolaborasi
Rencana keperawatan
Tujuan dan Kriteria Hasil Intervensi
Giaful Muharam STIKes Karsa Husada Garut
IMPLEMENTASI
Tgl/Jam No DP Implementasi Evaluasi Paraf
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Giaful Muharam STIKes Karsa Husada Garut
CATATAN PERKEMBANGAN
No Tanggal Dp Catatan Perkembangan Pelaksana
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