LAPORAN KASUS

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Tanggal ................................

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

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

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

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

Mengetahui,

Surabaya, ................ 20.....

Penguji Pendidikan

Penguji Lahan

______________________

______________________

PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN ANAK
STIKES HANG TUAH SURABAYA
Ruangan
Diagnosa medis
No. Register
Tgl/jam MRS
Tgl/jam pengkajian

I.

:
:
:
:
:

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

BIODATA
1. Identitas Anak
Nama

Anamnesa diperoleh dari :
1.
...........
2.
...........

:

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

II.

Hubungan

Nama ibu
Umur
Agama
Suku/bangsa
Pendidikan
Pekerjaan
Penghasilan
Alamat

:
:
:
:
:
:
:
:

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

Status Kesehatan

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.

.........................................................................................................................................
Riwayat terkena radiasi
:

d.

Berat badan selama hamil :

e.

Riwayat Imunisasi TT

f.

:

Golongan darah ibu .......................
........................................................
2. Natal
a. Tempat melahirkan :
b.

Jenis persalinan

c.

Penolong persalinan :

Golongan

darah

ayah

:

d.

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

g.

Konsumsi obat-obatan berbahaya tanpa anjuran dokter dan penggunaan zat/subtansi
kimia yang berbahaya
.........................................................................................................................................
.........................................................................................................................................
Perkembangan anak dibanding saudara-saudaranya
.........................................................................................................................................

h.

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

III. RIWAYAT IMUNISASI
No.

Waktu
Pemberian

Jenis Imunisasi

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

:

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

Lama Pemberian

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
:

) ya

(

) tidak

4. Orang tua selalu berkunjung ke RS
5. Yang akan tinggal dengan anak
:

) ya

(

) tidak

:(

B. Pemahaman anak tentang sakit dan rawat inap
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
IX. AKTIVITAS SEHARI-HARI
A. Nutrisi
No.
Kondisi
1

Frekwensi

2

Nafsu makan

3

Jenis makanan

SMRS

MRS

4

Alergi/pantangan/yang tidak disukai

B. Cairan
No.

Kondisi

1

Jenis minuman

2

Frekuensi minum

3

Kebutuhan cairan

4

Cara pemenuhan

C. Eliminasi
1. BAB
No.

Kondisi

1

Tempat pembuangan

2

Frekuensi

3

Konsistensi

4

Warna

5

Bau

6

Kesulitan

7

Obat pencahar

2. BAK
No.

Kondisi

1

Tempat pembuangan

2

Frekuensi

3

Warna

4

Kesulitan

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

Siang

b. Malam
2

Pola tidur

SMRS

MRS

SMRS

MRS

SMRS

MRS

SMRS

MRS

3

Kebiasaan sebelum tidur

4

Kesulitan tidur

E. Personal hygiene
No.
Kondisi
1 Mandi

2

3

4

a.

Cara

b.

Frekuensi

c.

Alat mandi

SMRS

MRS

Cuci rambut
a.

Frekuensi

b.

Cara

Gunting kuku
a.

Frekuensi

b.

Cara

Gosok gigi
a.

Frekuensi

b.

Cara

F. Olahraga
No.

Kondisi

1

Program olahraga

2

Jenis

3

Frekuensi

4

Kondisi setelah olahraga

G. Aktifitas / mobilitas fisik
No.
Kondisi
1

Kegiatan sehari-hari

2

Pengaturan jadwal harian

3

Penggunaan alat bantu aktifitas

4

Kesulitan pergerakan tubuh

SMRS

SMRS

MRS

MRS

H. Rekreasi
No.

X.
B.
C.

Kondisi

SMRS

1

Perasaan saat sekolah

2

Waktu luang

3

Perasaan setelah rekreasi

4

Waktu senggang keluarga

5

Kegiatan hari libur

MRS

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.

Penyebaran
:

3.

Mudah rontok
:

4.

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.

Sclera

:(

) icterus

(

) lain-lain,

3.

Conjungtiva

:(

) radang

(

) anemis

4.

Pupil

:(
(

) isokor
(
) midriasis (

) anisokor (
) lain-lain,

5.
6.
7.

Refleks cahaya
Posisi mata
Gerakan bola mata

:(
:(
:

) positif
) simetris

(
(

) negatif
) asimetris

8.

Penutupan kelopak mata :

9.

Keadaan bulu mata

) kabur

(

) diplopia

(

) lain-lain,
) myosis

:

10. Keadaan visus

:

11. Penglihatan

:(

Palpasi
Tekanan bola mata

:

(

) lain-lain,

Data lain :
.............................................................................................................................................
.............................................................................................................................................
Hidung & Sinus
 Inspeksi
1. Posisi hidung
:

I.

2.

Bentuk hidung

:

3.

Keadaan septum :

4.

Secret / cairan

:

Data lain :
.............................................................................................................................................
Telinga
 Inspeksi
1. Posisi telinga
:

J.

2.

Ukuran / bentuk telinga :

3.

Aurikel

:


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

Weber

:

3.

Swabach

:

Pemeriksaan vestibuler

) bersih
) ya

(
(

) serumen
) tidak

) ya

(

) tidak

(

) nanah

:

Data lain :
.............................................................................................................................................
K. Mulut
 Inspeksi

1.

2.
3.
4.

Gigi

Gusi
Lidah
Bibir

a. Keadaan gigi

:

b. Karang gigi / karies
c. Pemakaian gigi palsu
:
( ) merah
:
( ) kotor
:
( ) cianosis
( ) pecah

:(
:(
(
(
(
(

)
)
)
)
)
)

:(
:

) berbau

5. Mulut
6. Kemampuan bicara

ya
ya
radang
bersih
pucat
lain-lain,

(
(
(
(
(

)
)
)
)
)

tidak
tidak
lain-lain, ...................................
lain-lain, ...................................
basah
( ) kering

(

) tidak berbau

Data lain :
.............................................................................................................................................
L. Tenggorokan
1. Warna mukosa :

2.
3.
4.

Nyeri tekan
:(
Nyeri menelan : (
Data lain
:

) ya
) ya

M. Leher
 Inspeksi
Kelenjar thyroid

(
(

) tidak
) tidak

:(

) membesar (

) tidak

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

) teraba
(
) ya
(
) membesar (

) tidak
) tidak
) tidak

(

(

) lain-lain,

) lain-lain,

Data lain :
.............................................................................................................................................
N. Thorax dan pernapasan
 Inspeksi
1. Bentuk dada
:

2.

Irama pernafasan

:

3.

Pengembangan di waktu bernapas :

4.

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

:(

3. Nyeri tekan : (
Auskultasi
Peristaltik
:

) teraba

(

) tidak (

) ya

(

) tidak

) lain-lain,

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.

Gerakan kelopak mata

:

3.

Pergerakan bola mata

:

4.

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.

Refleks muntah

3.

Pengecapan 1/3 lidah bagian belakang :

4.

Suara

:

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

:

Mengangkat bahu

:

Hypoglossus
1. Deviasi lidah

:

2.

Kaku kuduk

:

3.

Kernig Sign

:

4.

Refleks Brudzinski :

5.

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

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