LAPORAN KASUS..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... Tanggal ................................

Oleh : _________________________ NIM ...............................

PROGRAM STUDI PENDIDIKAN PROFESI NERS SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA TA. 2011/2012

LEMBAR PENGESAHAN..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... Tanggal ................................

Oleh : _________________________ NIM ...............................

Mengetahui, Penguji Pendidikan

Surabaya, ................ 20..... Penguji Lahan

______________________

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PENGKAJIAN KEPERAWATAN ASUHAN KEPERAWATAN ANAK STIKES HANG TUAH SURABAYARuangan Diagnosa medis No. Register Tgl/jam MRS Tgl/jam pengkajian : : : : : ...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... Anamnesa diperoleh dari : 1. ........... 2. ...........

I.

BIODATA 1. Identitas Anak Nama Umur/tanggal lahir Jenis kelamin Agama Golongan darah

: : : : :

Bahasa yang dipakai : Alamat :

2. Identitas Orang Tua Nama ayah : ................................... Umur : ................................... Agama : ................................... Suku/bangsa : ................................... Pendidikan : ................................... Pekerjaan : ................................... Penghasilan : ................................... Alamat : ................................... 3. Identitas Saudara Kandung No. Nama Hubungan

Nama ibu Umur Agama Suku/bangsa Pendidikan Pekerjaan Penghasilan Alamat

: : : : : : : :

....................................... ....................................... ....................................... ....................................... ....................................... ....................................... ....................................... .......................................

Status Kesehatan

II.

RIWAYAT KESEHATAN A. Riwayat Kesehatan Sekarang 1. Keluhan utama ................................................................................................................................................ ................................................................................................................................................ 2. Riwayat penyakit sekarang ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

................................................................................................................................................ ................................................................................................................................................ B. Riwayat Kesehatan Lalu (Khusus untuk Anak Usia 0 5 Tahun) 1. Prenatal care a. Ibu memeriksakan kehamilannya setiap minggu di ......................................................................................................................................... b. Keluhan selama hamil yang dirasakan ibu : ......................................................................................................................................... c. d. e. f. ......................................................................................................................................... Riwayat terkena radiasi : Berat badan selama hamil : Riwayat Imunisasi TT : Golongan darah ayah

Golongan darah ibu ....................... ........................................................ 2. Natal a. Tempat melahirkan : b. c. d. Jenis persalinan :

Penolong persalinan :

Komplikasi yang dialami oleh ibu pada saat melahirkan dan setelah melahirkan ......................................................................................................................................... ......................................................................................................................................... 3. Post natal a. Kondisi bayi : .............................................................. APGAR b. Kesehatan anak saat lahir ......................................................................................................................................... ......................................................................................................................................... c. Penyakit masa kecil ......................................................................................................................................... pada umur : ........................ diberikan obat oleh : ............................................ d. Tindakan (operasi atau tindakan lain) ......................................................................................................................................... ......................................................................................................................................... e. Alergi ......................................................................................................................................... ......................................................................................................................................... f. Kecelakaan ......................................................................................................................................... ......................................................................................................................................... Konsumsi obat-obatan berbahaya tanpa anjuran dokter dan penggunaan zat/subtansi kimia yang berbahaya ......................................................................................................................................... ......................................................................................................................................... Perkembangan anak dibanding saudara-saudaranya .........................................................................................................................................

g.

h.

......................................................................................................................................... C. Riwayat Kesehatan Keluarga Genogram :

III. RIWAYAT IMUNISASI 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. Tumbuh gigi : ..................... bulan Jenis gigi : ....................... Jumlah gigi........ buah. B. Perkembangan Tiap tahap 1. Berguling : ..................... bulan 2. Duduk : ..................... bulan 3. Merangkak : ..................... bulan 4. Berdiri : ..................... tahun 5. Berjalan : ..................... tahun 6. Senyum kepada orang lain : ..................... tahun 7. Bicara pertama kali : ..................... tahun, dengan menyebutkan : 8. Berpakaian tanpa bantuan : ..................... tahun V. RIWAYAT NUTRISI A. Pemberian ASI .................................................................................................................................................... .................................................................................................................................................... B. Pemberian susu formula 1. Alasan pemberian : 2. Jumlah pemberian : 3. Cara pemberian : Lama Pemberian

C. Pola perubahan nutrisi tiap tahap usia sampai nutrisi saat ini Usia Jenis Nutrisi

VI. RIWAYAT PSIKOSOSIAL A. Anak tinggal bersama ....................................................................................... di ....................................................................................... B. Lingkungan berada di .................................................................................................................................................... .................................................................................................................................................... C. Rumah dekat dengan .................................................................................................................................................... Tempat bermain .................................................................................................................................................... Kamar klien .................................................................................................................................................... D. Rumah ada tangga : ya / tidak E. Hubungan dengan anggota keluarga .................................................................................................................................................... .................................................................................................................................................... F. Hubungan dengan teman sebaya .................................................................................................................................................... .................................................................................................................................................... G. Pengasuh anak .................................................................................................................................................... .................................................................................................................................................... VII. RIWAYAT SPIRITUAL A. Support sistem dalam keluarga: B. Kegiatan keagamaan :

VIII. REAKSI HOSPITALISASI A. Pengalaman keluarga tentang sakit dan rawat inap 1. Alasan Ibu membawa anak ke RS : 2. Apakah dokter menceritakan tentang kondisi anak : ( 3. Perasaan orang tua saat ini : 4. Orang tua selalu berkunjung ke RS 5. Yang akan tinggal dengan anak : :( ) ya ) ya ( ( ) tidak ) tidak

B. Pemahaman anak tentang sakit dan rawat inap ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... IX. AKTIVITAS SEHARI-HARI A. Nutrisi No. Kondisi 1 2 3 Frekwensi Nafsu makan Jenis makanan

SMRS

MRS

4

Alergi/pantangan/yang tidak disukai

B. Cairan No. 1 2 3 4

Kondisi

SMRS

MRS

Jenis minuman Frekuensi minum Kebutuhan cairan Cara pemenuhan

C. Eliminasi 1. BAB No. 1 2 3 4 5 6 7 2. BAK No. 1 2 3 4

Kondisi Tempat pembuangan Frekuensi Konsistensi Warna Bau Kesulitan Obat pencahar

SMRS

MRS

Kondisi Tempat pembuangan Frekuensi Warna Kesulitan

SMRS

MRS

D. Istirahat tidur No. Kondisi 1 Jam tidur a. Siang

SMRS

MRS

b. Malam 2 Pola tidur

3 4

Kebiasaan sebelum tidur Kesulitan tidur

E. Personal hygiene No. Kondisi 1 Mandi a. b. c. 2 Cara Frekuensi Alat mandi

SMRS

MRS

Cuci rambut a. b. Frekuensi Cara

3

Gunting kuku a. b. Frekuensi Cara

4

Gosok gigi a. b. Frekuensi Cara

F. Olahraga No. 1 2 3 4

Kondisi

SMRS

MRS

Program olahraga Jenis Frekuensi Kondisi setelah olahraga

G. Aktifitas / mobilitas fisik No. Kondisi 1 2 3 4 Kegiatan sehari-hari Pengaturan jadwal harian Penggunaan alat bantu aktifitas Kesulitan pergerakan tubuh

SMRS

MRS

H. Rekreasi No. 1 2 3 4 5 X. B. C.

Kondisi

SMRS

MRS

Perasaan saat sekolah Waktu luang Perasaan setelah rekreasi Waktu senggang keluarga Kegiatan hari libur

PEMERIKSAAN FISIK A. Keadaan umum :

Kesadaran : ...................................................................................................................... Tanda-tanda vital : 1. Tekanan darah : ................................. mmHg 2. Denyut nadi : ................................. x / menit 3. Suhu : ................................. C 4. Pernapasan : ................................. x / menit D. Berat Badan : .......................... kg E. Tinggi Badan : .......................... cm F. Kepala Inspeksi Keadaan rambut & Hygiene kepala 1. Warna rambut : 2. 3. 4. Penyebaran : Mudah rontok : Kebersihan rambut :

Palpasi 1. Benjolan : ( ) ada ( ) tidak ada 2. Nyeri tekan : ( ) ada ( ) tidak ada 3. Tekstur rambut : ( ) kasar ( ) halus Data lain : ............................................................................................................................................. G. Muka Inspeksi 1. Simetris : ( ) ya ( ) tidak 2. Bentuk wajah : 3. Gerakan abnormal :

4.

Ekspresi wajah :

Palpasi Nyeri tekan : ( ) ya ( ) tidak Data lain : ............................................................................................................................................. H. Mata Inspeksi 1. Palpebra : ( ) edema ( ) radang ( ) lain-lain, 2. 3. 4. 5. 6. 7. 8. 9. Sclera Conjungtiva Pupil Refleks cahaya Posisi mata Gerakan bola mata :( :( :( ( :( :( : ) icterus ) radang ( ( ) lain-lain, ) anemis ( ) lain-lain, ) myosis

) isokor ( ) midriasis ( ) positif ) simetris ( (

) anisokor ( ) lain-lain, ) negatif ) asimetris

Penutupan kelopak mata : Keadaan bulu mata : : :( : ) kabur ( ) diplopia ( ) lain-lain,

10. Keadaan visus 11. Penglihatan Palpasi Tekanan bola mata

I.

Data lain : ............................................................................................................................................. ............................................................................................................................................. Hidung & Sinus Inspeksi 1. Posisi hidung : 2. 3. 4. Bentuk hidung :

Keadaan septum : Secret / cairan :

J.

Data lain : ............................................................................................................................................. Telinga Inspeksi 1. Posisi telinga : 2. 3. Ukuran / bentuk telinga : Aurikel :

4. Lubang telinga :( 5. Pemakaian alat bantu :( Palpasi Nyeri tekan :( Pemeriksaan uji pendengaran 1. Rinne : 2. 3. Weber Swabach : : :

) bersih ) ya ) ya

( ( (

) serumen ) tidak ) tidak

(

) nanah

Pemeriksaan vestibuler

Data lain : ............................................................................................................................................. K. Mulut Inspeksi 1. Gigi a. Keadaan gigi b. Karang gigi / karies c. Pemakaian gigi palsu : ( ) merah : ( ) kotor : ( ) cianosis ( ) pecah 5. Mulut 6. Kemampuan bicara : :( :( ( ( ( ( :( : ) ) ) ) ) ) ya ya radang bersih pucat lain-lain, ( ( ( ( ( ( ) ) ) ) ) tidak tidak lain-lain, ................................... lain-lain, ................................... basah ( ) kering

2. 3. 4.

Gusi Lidah Bibir

) berbau

) tidak berbau

Data lain : ............................................................................................................................................. L. Tenggorokan 1. Warna mukosa : 2. 3. 4. Nyeri tekan :( Nyeri menelan : ( Data lain : ) ya ) ya ( ( ) tidak ) tidak

M. Leher Inspeksi Kelenjar thyroid

:(

) membesar ( ) teraba ( ) ya ( ) membesar (

) tidak ) tidak ) tidak ) tidak

(

) lain-lain,

Palpasi 1. Kelenjar thyroid : ( 2. Kaku kuduk :( 3. Kelenjar limfe : (

(

) lain-lain,

Data lain : ............................................................................................................................................. N. Thorax dan pernapasan Inspeksi 1. Bentuk dada : 2. Irama pernafasan :

3. 4.

Pengembangan di waktu bernapas : Tipe pernapasan : : :

Palpasi 1. Vokal fremitus 2. Massa / nyeri

Auskultasi 1. Suara nafas : ( ) vesikuler ( ) bronchial ( ) bronchovesikuler 2. Suara tambahan : ( ) ronchi ( ) wheezing ( ) rales Perkusi ( ) hypersonor ( ) pekak ( ) redup ( ) tympani Data lain : ............................................................................................................................................. O. Jantung Palpasi Ictus cordis : Perkusi Pembesaran jantung : Auskultasi ( ) s1s2 tunggal ( ) murmur ( ) gallop ( ) lain-lain,

Data lain : ............................................................................................................................................. P. Abdomen Inspeksi 1. Membuncit : ( ) ya ( ) tidak 2. Luka : ( ) ya ( ) tidak Palpasi 1. Hepar : ( ) teraba ( ) tidak ( ) lain-lain, 2. Lien :( ) teraba ) ya ( ( ) tidak ( ) tidak ) lain-lain,

3. Nyeri tekan : ( Auskultasi Peristaltik :

Perkusi : ( ) redup ( ) tympani Data lain : ............................................................................................................................................. Q. Genitalia dan anus : .................................................................................................................................................... .................................................................................................................................................... ....................................................................................................................................................

R. Ekstremitas Ekstremitas atas 1. Motorik a. Pergerakan kanan / kiri b. Pergerakan abnormal

: :

c. Kekuatan otot kanan / kiri : d. Tonus otot kanan / kiri e. Koordinasi gerak 2. Refleks a. Biceps kanan / kiri b. Triceps kanan / kiri 3. Sensori a. Nyeri b. Rangsang suhu c. Rasa raba Ekstremitas bawah 1. Motorik a. Gaya berjalan b. Kekuatan kanan / kiri : : :( : : ) ya ( ) tidak : :

: :

c. Tonus otot kanan / kiri : 2. Refleks a. KPR kanan / kiri b. APR kanan / kiri c. Babinsky kanan / kiri 3. Sensori a. Nyeri b. Rangsang suhu c. Rasa raba

: : :

:( : :

) ya

(

) tidak

Data lain : ............................................................................................................................................. S. Status Neurologi

Penciuman : Penglihatan : Oculomotorius, Trochlearis, Abducens 1. Konstriksi pupil : 2. 3. 4. Gerakan kelopak mata Pergerakan bola mata : :

Pergerakan mata ke bawah & dalam :

Trigeminus 1. Sensibilitas / sensori : 2. Refleks dagu 3. Refleks cornea : : :

Facialis 1. Gerakan mimik

2. Pengecapan 2/3 lidah bagian depan : Fungsi pendengaran : ............................................................................................................................................. : ............................................................................................................................................. Glosopharingeus dan Vagus 1. Refleks menelan : 2. 3. 4. Refleks muntah Pengecapan 1/3 lidah bagian belakang : Suara : :

Assesorius 1. Memalingkan kepala ke kiri dan ke kanan : 2. Mengangkat bahu : : : :

Hypoglossus 1. Deviasi lidah 2. 3. 4. 5. Kaku kuduk Kernig Sign

Refleks Brudzinski : Refleks Lasegu :

Data lain : .............................................................................................................................................

XI. TINGKAT PERKEMBANGAN (0-6 Tahun Menggunakan DDST) A. Adaptasi Sosial .................................................................................................................................................... .................................................................................................................................................... B. Bahasa .................................................................................................................................................... .................................................................................................................................................... C. Motorik Halus .................................................................................................................................................... .................................................................................................................................................... D. Motorik Kasar .................................................................................................................................................... .................................................................................................................................................... E. Kesimpulan dan Pemeriksaan Perkembangan .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... XII. PEMERIKSAAN PENUNJANG A. Laboratorium ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... B. Rontgen ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... C. Terapi ...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................

Surabaya, .....................

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

ANALISA DATA Nama klien Umur .No : .............................................. : .............................................. Data Ruangan/kamar : .............................................. No. register : .............................................. Penyebab Masalah

PRIORITAS MASALAH Nama klien Umur No. : .............................................. : .............................................. Diagnosa Keperawatan Ruangan/kamar : .............................................. No. register : .............................................. Tanggal Ditemukan Teratasi Nama Perawat

No.

Diagnosa Keperawatan

Tujuan

RENCANA KEPERAWATAN Intervensi

Rasional

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN No. Tgl/jam Tindakan TT Tgl/jam Catatan Perkembangan TT