FORMAT ASUHAN KEPERAWATAN ANAK

STIKES WIRA MEDIKA PPNI BALI

Nama Mahasiswa
NIM
Tempat Praktek
Tanggal

I.

IDENTITAS PASIEN
Nama
No Rekam Medis
Tempat/ tanggal lahir
Umur
Jenis Kelamin
Suku bangsa
Bahasa yang dimengerti
Agama
Nama Ayah/ Ibu/ wali
Pendidikan ayah/ibu/wali
Pekerjaan ayah/ibu/wali
Alamat/ no telp
Diagnosa medis

II.

III.

: ..................................................................
: ..............
: ..............
: Pengkajian :...............................................................................
Praktik
:...............................................................................

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

KELUHAN UTAMA
.............................................................................................................................................
.............................................................................................................................................
RIWAYAT KESEHATAN SAAT INI
.............................................................................................................................................
.............................................................................................................................................
...............................................................................................................................
.............................................................................................................................
.............................................................................................................................
............................................................................................................................
............................................................................................................................

IV. RIWAYAT KESEHATAN MASA LALU

a. Pre natal
Saat hamil
: Ibu merokok
: (ya/ tidak)
Ibu minum minuman keras : (ya/ tidak)
b. Intra dan post natal
Intranatal
Lama persalinan
: ....................................................................................
Saat persalinan
: prematur/ matur/ serotinus
Komplikasi persalinan : ....................................................................................
Terapi yang diberikan
: ....................................................................................
....................................................................................
Cara melahirkan
: Pervaginam normal
(
)
Dengan vakum ekstraksi
(
)
Operasi caesar
(
)
Lainnya ......................................................................
Tempat melahirkan
: Rumah Sakit
(
)
Rumah Bersalin
(
)
Rumah
(
)
Lainnya .......................................................................
Postnatal
Usaha nafas
: Dengan bantuan
(
)
Tanpa bantuan
(
)
Kebutuhan resusitasi
: .....................................................................................
Apgar skor
: .....................................................................................
Bayi langsung menangis : ya/ tidak
Tangisan bayi
:kuat/lemah/ lainnya (sebutkan)...................................
Obat-obatan yang diberikan setelah lahir............................................................
.............................................................................................................................
Trauma lahir
: Ada (
)
Tidak (
)
Narkosis
: Ada (
)
Tidak (
)
Keluarnya urin/ BAB
: Ada (
)
Tidak (
)
Respon fisiologis atau prilaku yang bermakna :..................................................
.............................................................................................................................
c. Penyakit yang pernah diderita : ...................................................................................
d. Hospitalisasi
: ...................................................................................
e. Operasi
: ...................................................................................
f. Injuri/ kecelakaan
: ...................................................................................
g. Alergi
: ...................................................................................

h. Imunisasi
i. Pengobatan

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

V.

RIWAYAT PERTUMBUHAN
.............................................................................................................................................
.............................................................................................................................................
VI. TINGKAT PERKEMBANGAN (Gunakan Format DDST II dan lampirkan)
a. Sosial.
.....................................................................................................................................
.....................................................................................................................................
............................................................................................................................
b. Motorik halus
.....................................................................................................................................
.....................................................................................................................................
............................................................................................................................
c. Bahasa
.....................................................................................................................................
.....................................................................................................................................
............................................................................................................................
d. Motorik kasar
......................................................................................................................................
......................................................................................................................................
............................................................................................................................
VII. RIWAYAT SOSIAL
a. Pengasuh
: .......................................................................
b. Pembawaan secara umum
: .......................................................................
c. Hubungan dengan anggota keluarga : .......................................................................
d. Hubungan dengan teman sebaya
: .......................................................................
VIII. RIWAYAT KELUARGA
a. Sosial ekonomi :
......................................................................................................................................
b. Lingkungan rumah :
......................................................................................................................................
c. Penyakit keluarga :
......................................................................................................................................
Genogram

IX. POLA KESEHATAN

a. Pemeliharaan dan persepsi kesehatan
.......................................................................................................................................
........................................................................................................................
.......................................................................................................................
.......................................................................................................................
b. Nutrisi (makanan dan cairan)
.......................................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
c. Aktifitas
.......................................................................................................................................
.........................................................................................................................
d. Tidur dan istirahat
.......................................................................................................................................
........................................................................................................................
e. Eliminasi
.......................................................................................................................................
........................................................................................................................
........................................................................................................................
f. Pola hubungan
.......................................................................................................................................
g. Koping
.......................................................................................................................................
h. Kognitif dan persepsi
.......................................................................................................................................
i. Konsep diri
.......................................................................................................................................
j. Seksual
......................................................................................................................................
k. Nilai
.......................................................................................................................................
X.

PEMERIKSAAN FISIK (inspeksi auskultasi)

a. Keadaan umum
: ....................................................................................................
Tingkat kesadaran : ................................................................................................
TD
: ...........mmHg
Nadi : .......... x/menit
RR
:...x/menit
BB
: ........... kg
TB
: .......... cm
Suhu badan : ......... o C

b.

c.

d.

e.

LLA : ........... cm
LK
: .......... cm
LP
: .......... cm
Kulit
.....................................................................................................................................
...........................................................................................................................
Kepala
....................................................................................................................................
...........................................................................................................................
............................................................................................................................
Mata
....................................................................................................................................
...........................................................................................................................
............................................................................................................................
Telinga
.....................................................................................................................................
....................................................................................................................................
...........................................................................................................................

f. Hidung
.....................................................................................................................................
....................................................................................................................................
...........................................................................................................................
g. Mulut
.....................................................................................................................................
....................................................................................................................................
...........................................................................................................................
h. Leher
.....................................................................................................................................
....................................................................................................................................
...........................................................................................................................
i. Dada
Paru-paru
.....................................................................................................................................
....................................................................................................................................
...........................................................................................................................
Jantung
.....................................................................................................................................

....................................................................................................................................
...........................................................................................................................
j. Abdomen
....................................................................................................................................
....................................................................................................................................
...........................................................................................................................
.
k. Genetalia
.....................................................................................................................................
....................................................................................................................................
...........................................................................................................................
l. Ekstrimitas
.....................................................................................................................................
....................................................................................................................................
...........................................................................................................................
m. Neurologi
.....................................................................................................................................
....................................................................................................................................
...........................................................................................................................
XI. PEMERIKSAAN DIAGNOSTIK PENUNJANG

XII. TERAPI YANG DIPEROLEH (KOLOM)

XIII. INFORMASI LAIN (mencakup rangkuman kesehatan klien dari gizi, fisioterapis, dll)

XIV. ANALISIS DATA

DATA
DS :
DO :

PENYEBAB/ ETIOLOGI

MASALAH/ PROBLEM

XV. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS MASALAH

1. ...
2.
3.

...

4.

...

XVI. RENCANA KEPERAWATAN

No
NO
Tujuan dan Kriteria
Diagnosa
Hasil (NOC)
Keperaw
atan
1

Intervensi
(NIC)

Rasional

Nama/TTD

XVII.

CATATAN PERKEMBANGAN
No Tanggal/
No.
Implementasi
jam
Diagnosa
1
2
3

XVIII.

Evaluasi
No tanggal
1

No.
Diagnosa

Jam

Evaluasi proses
Respon
DS
DO
DS
DO
DS
DO

Evaluasi

Nama/TTD

Nama/TTD

S
O
A
P

Denpasar, 20..
Mahasiswa,

()