Asuhan Keperawatan Aplikasi NANDA, NOC, NIC: LAPORAN KASUS ASUHAN KEPERAWATAN

LAPORAN KASUS

A. Manajemen Asuhan keperawatan

1. Pengkajian

Tempat Praktek :

Tanggal Praktek :

Tanggal Pengkajian :

Tanggal Klien Masuk RS :

a. Identitas Anak

Nama Anak : BB/TB :

Tempat Tanggl lahir/Usia:

Jenis Kelamin :

Pendidikan Anak : Anak ke- :

Nama Ibu : Nama Ayah :

Pekerjaan : Pekerjaan :

Pendidikan : Pendidikan :

Alamat : Pendidikan :

Diagnosa Medis :

b. KELUHAN UTAMA (Alasan Masuk RS)

c. RIWAYAT KEHAMILAN DAN KELAHIRAN

1. Prenatal :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2. Intranatal

:...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Postnatal :

d. RIWAYAT KESEHATAN DAHULU

1. Penyakit yang diderita sebelumnya :

2. Pernah dirawat di RS:

3. Obat- obatan yang pernah digunakan:

4. Alergi:

5. Kecelakaan :

6. Riwayat imunisasi :

Jenis Imunisasi	waktu
BCG	1 bulan (bekas jaringan parut ( )
DPT
POLIO
Campak
Hepatitis B

Kesan : Imunisasi Dasar

e. RIWAYAT KESEHATAN SAAT INI

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

f. RIWAYAT KESEHATAN KELUARGA

g. RIWAYAT TUMBUH KEMBANG

1. Kemandirian dan bergaul :

2. Motorik Kasar

3. Motorik Halus

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

4. Kognitif dan Bahasa :

5. Psikososial

6. Perkembangan Psikomotor

Tengkurap :

Duduk :

Berdiri :

Berjalan :

Bicara :

Kesan :

Kesimpulan :

h. Riwayat Sosial

1. Yang mengasuh klien

2. Hubungan dengan anggota keluarga

3. Hubungan dengan teman sebaya

4. Pembawaan secara umum :

5. Lingkungan rumah :

i. PEMERIKSAAN FISIK

1. Keadaan umum :

2. TB/ BB (cm) :

3. Vital Signs

Blood Pressure :

Heart Rate :

Respiration Rate :

Temperature :

4. BB/ TB :

5. Kepala

a. Lingkar kepala :

b. Rambut : Kebersihan ………….....................

Warna…………. .............. Tekstur…………….............

Distribusi rambut………..........................................................

Kuat/mudah tercabut……........................................................

6. Mata : Simetris

Sclera :

Konjungtiva :

Palpebra :

Pupil :Ukuran……....................................

Bentuk……..............................................................

Reaksi Cahaya……...........................................

7. Telinga : Simetris …… .................................

Serumen……

Pendengaran………..

8. Hidung : Septum

simetris….

Sekret …….

Polip………..

9. Mulut :

Kebersihan……..

Warna Bibir……..

Kelembapan………

a. Lidah :

b. Gigi :

10. Leher

a. Kelenjer Getah Bening:

b. Kelenjer Tiroid :

c. JVP :

11. Dada / thorak

a. Inspeksi :

b. Palpasi :

c. Perkusi :

d. Auskultasi :

12. Jantung

a. Inspeks :

b. Palpasi :

c. Auskultasi :

13. Abdomen

a. Inspeksi :

b. Palpasi :

c. Perkusi :

d. Auskultasi :

14. Punggung : Bentuk……

15. Ekstremitas : Kekuatan dan tonus otot ……

refleks- refleks……

a. Atas :

b. Bawah :

Kekuatan Otot

16. Genitalia :

17. Kulit : Warna

Tugor

Integritas

Elastisitas

18. Pemeriksaan neurologis :

j. PEMERIKSAAN TUMBUH KEMBANG

- DDST

- STATUS NUTRISI

k. PEMERIKSAAN PSIKOSOSIAL
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

l. PEMERIKSAAN SPIRITUAL

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

m. PEMERIKSAAN PENUNJANG

1. Laboratorium Hematologi :

No	Parameter	Hasil	Satuan	Nilai Normal
1	Hemoglobin
2	Hematokrit
3	Leukosit
4	Trombosit

Kesan :

2. Pemeriksaan Kimia Klinik

No	Parameter	Hasil	Satuan	Nilai Normal
1
2
3
4
5
6

3. Rontgen :

4. Lain-lain :

n. AKTIFITAS DAN LATIHAN

No	Aktifitas dan latihan	Sehat	Sakit
1	Makan
2	Minum
3	Tidur
4	Mandi
5	Eliminasi
6	Bermain

o. Terapi

Terapi Farmakologi

Terapi Non Farmakologi

p. RINGKASAN RIWAYAT KEPERAWATAN

(Berisikan tentang alasan masuk RS, identitas, BB dan PB, TTV, semua data/ pengkajian yang abnormal/data fok dan nantinya akan dimasukkan sebagai DO dan DS)

2. ANALISIS DATA

Nama Klien :

No MR :