ASUHAN KEPERAWATAN ANAK PADA BY “ S” DENGAN DIAGNOSA

MEDIS ASFIKSIA DIRUANG NICU RSUP NTB

Nama Mahasiswa : __________ Ruangan : ___________

NIM : __________ No. RM : ___________
Tanggal Pengkajian : __________ Jam : ___________

I. IDENTITAS PASIEN
Nama : _______
Jenis Kelamin : _______
Tempat tanggal lahir : _______
Umur : _______
Anak ke : _______
Nama Ayah : _______
NamaIbu : _______
Pendidikan Ayah : _______
Pendidikan Ibu : _______
Agama : _______
Suku/Bangsa : _______
Alamat : _______
Tanggal MRS : _______
Diagnosa Medis : ______________
Sumber Informasi : ______________
II. RIWAYAT KEPERAWATAN (NURSING HISTORY)
1. Keluhan Utama:
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2. Riwayat penyakit sekarang:
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3. Riwayat kehamilan dan persalinan :
a. Prenatal:
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 b. Natal:
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c. Posnatal:
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4. Riwayat kesehatan keluarga :
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5. Genogram

Keterangan:
: laki-laki/perempuan
: laki-laki/perempuan meninggal
: klien/ pasien
: garis perkawinan
: garis keturunan
: tinggal serumah

6. Riwayat sosial:
a. Sistem pendukung keluarga
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 b. Hubungan orang tua dengan bayi
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c. Lingkungan rumah
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d. Problem sosial yang penting
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III. PEMERIKSAAN FISIK (Head to toe)
1. Keadaan umum : _____________
2. Kesadaran : _____________
3. Vital Sign :
 Suhu : _____________
 Nadi : _____________
 RR : _____________
BB : ____________________________________________
PB : ____________________________________________
Lingkar kepala : ____________________________________________
4. Refleks
a. Reflek moro : ______________________________________________________
b. Reflek menggenggam: _______________________________________________
c. Reflek menghisap: __________________________________________________
5. Tonus otot/aktivitas
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6. Kekuatan menangis
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7. Kepala : ____________________________________________________.
a. Fontanela anterior : ___________________________________________________________
b. Sutura sagitalis : ___________________________________________________________
c. Bentuk : ___________________________________________________________
d. Gambaran wajah : ___________________________________________________________
e. Mata : ___________________________________________________________
f. Telinga : ___________________________________________________________
g. Hidung : ____________________________________________________________
h. Mulut : ____________________________________________________________
i. Tenggorokan : ____________________________________________________________
8. Leher
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9. Dada/thorax
a. Simetris : __________________________________________________________
b. Retraksi dada : ___________________________________________________________
c. Ketinggalan gerak : ____________________________________________________________
10. Paru-paru
a. Suara dasar : _____________
b. Suara tambahan : _____________
c. Suara nafas : _____________
d. Bunyi nafas : _____________
e. Respirasi spontan : _____________
11. Jantung
a. Bunyi jantung I dan II murni : _____________
b. Bunyi jantung tambahan : ________________
12. Abdomen
a. Bentuk : _______________________________________.
b. Bising usus : _______________________________________
c. Peristaltik : _______________________________________
 d. Nyeri tekan : _______________________________________
13. Genetalia : _______________________________________
14. Anus : _______________________________________
15. Ekstremitas : _______________________________________

a. Gerak : __________________________
b. Tonus : __________________________
c. Trofi : __________________________
d. Reflek patologis : __________________________
11. Perkembangan
a. Menangis bila nyaman
b. Membuat suara tenggorokan pelan
c. Memandang wajah dengan sungguh-sungguh
d. Mengeluarkan suara
e. Berespon secara berbeda terhadap objek berbeda
f. Dapat tersenyum
g. Bereaksi terhadap sumber cahaya
h. Mengoceh dan memberi reaksi pada suara
i. Membalas senyuman

IV. KEADAAN KESEHATAN SAAT INI

1. Diagnosa Medis : ____________________________________________________________
2. Status nutrisi : ____________________________________________________________
a. BB lahir : ___________________________
b. BB sekarang : ___________________________
c. PB : ___________________________
d. Lingkar dada : ___________________________
e. Lingkar kepala : ___________________________
f. Lingkar lengan atas : ___________________________

g. Status cairan
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h. Aktivitas :
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i. Istirahat dan tidur
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j. Tindakan keperawatan yang telah dilakukan
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