Asuhan Keperawatan
................................................................................
........................................................................
.......................................................
A.
Identitas Mahasiswa
Nama : ..............................
Ruangan : ..............................
B.
Identitas Pasien
Nama : ..............................
TTL : ..............................
Usia : ..............................
Nama Ayah/Ibu : ..............................
Pekerjaan Ayah/Ibu : ..............................
Alamat : ..............................
..............................
Agama : ..............................
Suku bangsa : ..............................
Pendidikan Ayah/Ibu : ..............................
C.
Riwayat kesehatan
1. Keluhan utama
........................................................................................................................................................................................................................................................................................
2. Riwayat kehamilan
dan kelahiran
a. Prenatal :
................................................................................................................................................................................................................................................................................
b.
Intranatal: ................................................................................................................................................................................................................................................................................
c. Postnatal
................................................................................................................................................................................................................................................................................
3.
Riwayat kesehatan masa lalu
a. Penyakit
waktu kecil :
............................................................................
............................................................................
b. Pernah
dirawat RS : ............................................................................
............................................................................
c. Obat-obatan
yang digunakan : ............................................................................
............................................................................
d. Tindakan
(operasi) : ............................................................................
............................................................................
e. Alergi : ............................................................................
............................................................................
f. Kecelakaan : ............................................................................
............................................................................
g. Imunisasi : ............................................................................
............................................................................
4.
Riwayat penyakit keluarga
....................................................................................................................................................................................................................................................................................................................................................................................................................................
Genogram :
5.
Riwayat Sosial
a. Yang
mengasuh :
............................................................................
........................................................................................................................................
b. Hubungan
dengan anggota keluarga : ............................................................................
........................................................................................................................................
c. Hubungan
dengan teman sebaya : ............................................................................
........................................................................................................................................
d. Pembawaan
secara umum : ............................................................................
........................................................................................................................................
e. Lingkungan
rumah : ............................................................................
........................................................................................................................................
D.
Kebutuhan dasar
1. Makanan
· Yang
disukai/tidak disukai :
........................................................................................
........................................................................................
· Alat
makan yang dipakai : ........................................................................................
........................................................................................
· Pola
makan/jam :
........................................................................................
........................................................................................
2. Pola tidur
· Kebiasaan
sebelum tidur : ........................................................................................
........................................................................................
· Tidur
siang : ........................................................................................
........................................................................................
· Tidur
malam : ........................................................................................
........................................................................................
3. Mandi :
........................................................................................
............................................................................................................................................
4. Aktivitas bermain : ........................................................................................
............................................................................................................................................
5. Eliminasi
· BAB : ........................................................................................
........................................................................................
· BAK : ........................................................................................
........................................................................................
E.
Keadaan kesehatan sekarang
1.
Diagnosa medis :
.......................................................................................
2.
Tindakan operasi : ........................................................................................
3.
Status nutrisi :
........................................................................................
........................................................................................
4.
Status cairan : ........................................................................................
........................................................................................
5.
Obat-obatan : ........................................................................................
6.
Aktifitas : ........................................................................................
........................................................................................
7.
Tindakan keperawatan : ........................................................................................
........................................................................................
8.
Hasil laboratorium : Dilampirkan
9.
Hasil Rontgen : Kesan, ............................................................................
........................................................................................
........................................................................................
10. Data
Tambahan : ........................................................................................
F.
Pemeriksaan Fisik
1. Keadaan
umum :
2. Tanda-tanda
vital :
TD: RR: S: N:
3. TB/BB : BB: .....Kg
TB: ......Cm
4. Lingkar
kepala : .......Cm
5. Mata
:
....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................
6. Hidung :
....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
7. Mulut :
....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................
8. Telinga :
....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................
9. Leher :
....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................
10.
Dada :
....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................
11.
Paru-paru : ....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................
12.
Jantung :
....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................
13.
Punggung :
....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
14.
Genitalia :
....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................
15.
Kulit :
....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................
16.
Nyeri :
....................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................
17.
Pemeriksaan tingkat perkembangan
a.
Kemandirian dan sosialisasi :
............................................................................
.................................................................................................................................
.................................................................................................................................
b.
Motorik halus : ............................................................................
.................................................................................................................................
.................................................................................................................................
c.
Kognitif dan bahasa : ............................................................................
.................................................................................................................................
.................................................................................................................................
d.
Motorik kasar : ............................................................................
.................................................................................................................................
.................................................................................................................................
Informasi lain :
............................................................................
G. Analisa Data
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