STIKES RS.

BAPTIS KEDIRI
PRODI KEPERAWATAN S1
FORMAT ASUHAN KEPERAWATAN ANAK
NAMA MAHASISWA

: .

NIM

: .

RUANG

: .

TANGGAL

: .

1.

BIODATA :
A. Identitas Pasien
Nama Pasien
Nama Panggilan
Umur
Jenis Kelamin
Agama
Pendidikan
Alamat

: .No.Reg
: .
: .
: .
: .
: .
: .

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Diagnosa Medis
Tanggal MRS
Tanggal Pengkajian
Golongan Darah

: .
: .
: .
: .

B. Identitas Orang Tua

Nama Ayah
Umur
Agama
Pendidikan
Pekerjaan
Penghasilan
Alamat
2.

:
:
:
:
:
:
:

Nama Ibu
Umur
Agama
Pendidikan
Pekerjaan
Penghasilan
Alamat

:
:
:
:
:
:
:

ALASAN KUNJUNGAN / KELUHAN UTAMA

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

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3.

4.

RIWAYAT KEHAMILAN DAN KELAHIRAN

A . Prenatal
: ...........................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
B. Natal
: ...........................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
C. Post Natal : ...........................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
RIWAYAT PENYAKIT MASA LALU
A. Penyakit Penyakit Waktu Kecil
.................................................................................................................................................
.................................................................................................................................................
B. Pernah Dirawat di Rumah Sakit
.................................................................................................................................................
.................................................................................................................................................
C.Penggunaan Obat Obatan
.................................................................................................................................................
.................................................................................................................................................
D. Tindakan (misalnya: Operasi atau Tindakan Lainnya)
.................................................................................................................................................
.................................................................................................................................................
E.Alergi

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.................................................................................................................................................
.................................................................................................................................................
F. Kecelakaan
.................................................................................................................................................
.................................................................................................................................................
G. Imunisasi
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
5.

RIWAYAT KESEHATAN KELUARGA

.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
GENOGRAM

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6.

DATA PSIKO SOSIAL

A. Yang Mengasuh Anak
............................................................................................................................................
............................................................................................................................................
B. Hubungan Dengan Anggota Keluarga
............................................................................................................................................
............................................................................................................................................
C. Hubungan Dengan Teman Sebaya
............................................................................................................................................
............................................................................................................................................
D. Pembawaan Secara Umum
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
7. KEBUTUHAN DASAR / POLA SEHARI HARI
A. Makanan yang di Sukai / Tidak di Sukai
............................................................................................................................................
............................................................................................................................................
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Selera Makan
............................................................................................................................................
............................................................................................................................................
Alat Makan yang di Gunakan
............................................................................................................................................
............................................................................................................................................
Jam Makan
............................................................................................................................................
............................................................................................................................................
B. Pola Tidur
............................................................................................................................................
............................................................................................................................................
Kebiasaan Kebiasaan Sebelum Tidur (Apakah perlu mainan, perlu dibacakan cerita seBelum dibawakan tidur ?)
............................................................................................................................................
............................................................................................................................................
Mandi
............................................................................................................................................
............................................................................................................................................
Aktifitas / Bermain
............................................................................................................................................
............................................................................................................................................
Eliminasi
............................................................................................................................................
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............................................................................................................................................
............................................................................................................................................
8. KEADAAN KESEHATAN SAAT INI / PENAMPILAN UMUM PASIEN
A. Diagnosa Medis
............................................................................................................................................
B. Tindakan Operasi
............................................................................................................................................
............................................................................................................................................
C. Status Nutrisi
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
D. Status Hidrasi
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
E. Obat Obatan
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
F. Aktifitas
............................................................................................................................................
............................................................................................................................................
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............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
G. X ray
............................................................................................................................................
............................................................................................................................................
9. TANDA-TANDA VITAL
Suhu Tubuh : C
Denyut Nadi : x/menit
Tekanan Darah : mmHg
Pernafasan
:x/menit
TT / TB
: Kg, .cm
10. PEMERIKSAAN FISIK
A. Keadaan Umum
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
B. Pemeriksaan Kepala dan Leher
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
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C.

D.

E.

F.

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
Pemeriksaan Dada / Thorak
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
Pemeriksaan Addomen
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
Pemeriksaan Genetalia dan Sekitarnya
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
Punggung (Skoliosis, Kypose, Hyperlordose)
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

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G. Pemeriksaan Neurologi
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
H. Pemeriksaan Integumen
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
G. Pemeriksaan Ekstremitas (Oedema, Kelainan Kongenital, Reflek Patella)
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
11. PEMERIKSAAN TINGKAT PERKEMBANGAN
A. Adaptasi Sosial
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
B. Bahasa
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10

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
C. Motorik Halus
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
Motorik Kasar
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
Kesimpulan Dari Pemeriksaan Tumbuh Kembang Anak
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
15. INFORMASI LAIN
..................................................................................................................................................
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11

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

Kediri , .
Tanda Tangan Mahasiswa,

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12

ANALISA DATA
NAMA PASIEN : ...............................................................
UMUR
: ..............................................................
NO. REGISTER : ..............................................................
DATA GAYUT
DATA OBYEKTIF
DATA SUBYEKTIF

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MASALAH

KEMUNGKINAN
PENYEBAB

13

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14

DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN : ...............................................................
UMUR
: ..............................................................
NO. REGISTER : ..............................................................
NO
TANGGAL
DIAGNOSA KEPERAWATAN
MUNCUL

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TANGGAL
TERATASI

TANDA
TANGAN

15

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16

RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN
NO.REGISTER
NO

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

DIAGNOSA KEPERAWATAN

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TUJUAN

INTERVENSI

RASIONAL

TTD

17

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18

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TINDAKAN KEPERAWATAN
NAMA PASIEN
UMUR
NO.REGISTER
NO

NO.DX

: ..............................................................
: ...............................................................
: .............................................................
TGL/JAM

Komp.B/Data D/ Format Askep 2008

TINDAKAN KEPERAWATAN

TANDA
TANGAN

20

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21

CATATAN PERKEMBANGAN
NAMA PASIEN
UMUR
TANGGAL
NO

NO.DX

: ..............................................................
: ...............................................................tahun / bulan
: ...............................................................
JAM

Komp.B/Data D/ Format Askep 2008

EVALUASI

22

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