Aplikasi Merah Putih

Assalamualaikum.
dalam rangka memeriahkan hari kemerdekaan Indonesia, telah hadir aplikasi merah putih terbaru untuk mendapatkan pulsa gratis. Sudah terbukti dapat pulsa langsung. Sebarkan berita gembira ini. Download aplikasinya lewat link dibawah ini :
https://invite.cashtree.id/fd659d

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)
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2.      ANALISIS DATA

Nama Klien                     :
No MR                            :

Hari/ Tgl
Data
Patofisiologi
Masalah






















































































3.             DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................






























4.             Rencana  Asuhan Keperawatan
No
Diagnosa  Keperawatan
Criteria Hasil/ NOC
Interventions / NIC
Aktifitas


















CATATAN PERKEMBANGAN
Hari / Tanggal  :                                                                                                           Ruangan        :
Nama Klien      :                                                                                                           No MR           :

JAM
Diagnosa  Keperawatan
IMPLEMENTASI
EVALUASI
















5.                CATATAN PERKEMBANGAN
Diagnosa Keperawatan
Catatan Perkembangan
Nama & Paraf Perawat






























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