FORMAT ASUHAN KEPERAWATAN ANAK

STIKES WIRA MEDIKA PPNI BALI

Nama Mahasiswa

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

NIM

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

Tempat Praktek

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

Tanggal

: Pengkajian
Praktik

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

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

II.

Tanggal MRS

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

Diagnosa medis

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

KELUHAN UTAMA
.............................................................................................................................................

.............................................................................................................................................
III.

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 (

c.

Penyakit yang pernah diderita : ...................................................................................

d.

Hospitalisasi
: ...................................................................................

e.

Operasi

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

f.

Injuri/ kecelakaan

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

g.

Alergi

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

...
h.

Imunisasi

i.

Pengobatan
Nama obat

V.

: ...................................................................................
Dosis

Rute

Indikasi

RIWAYAT PERTUMBUHAN
.............................................................................................................................................
.............................................................................................................................................

VI. TINGKAT PERKEMBANGAN (Gunakan Format DENVER II dan lampirkan)

a. Sosial.
.....................................................................................................................................
.....................................................................................................................................
b. Motorik halus
.....................................................................................................................................
.....................................................................................................................................
c. Bahasa

.....................................................................................................................................
.....................................................................................................................................
d. Motorik kasar
......................................................................................................................................
......................................................................................................................................
VII. RIWAYAT SOSIAL
a. Hubungan dengan anggota keluarga : .......................................................................
b. Hubungan dengan teman sebaya

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

VIII. RIWAYAT KELUARGA

a. Sosial ekonomi :
......................................................................................................................................
b. Lingkungan rumah :
......................................................................................................................................
c. Penyakit keluarga :
......................................................................................................................................
d. 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. Kognitif
.......................................................................................................................................
h. Konsep diri
.......................................................................................................................................
i. Seksual
......................................................................................................................................
j. 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

LLA

: ........... cm

LK

: .......... cm

LP

: .......... cm

b. Kepala
.....................................................................................................................................
c. Mata
.....................................................................................................................................
d. Telinga
.....................................................................................................................................
e. Hidung
.....................................................................................................................................
f. Mulut
.....................................................................................................................................
g. Leher

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

h. Dada
Paru-paru
.....................................................................................................................................
Jantung
.....................................................................................................................................
i. Abdomen
.....................................................................................................................................
j. Genetalia
.....................................................................................................................................
k. Ekstrimitas
.....................................................................................................................................
l. Neurologi
.....................................................................................................................................
XI. PEMERIKSAAN DIAGNOSTIK PENUNJANG

XII. TERAPI YANG DIPEROLEH

Nama obat

Dosis

Rute

Indikasi

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

XIV. ANALISIS DATA

SIGN & SYMPTON

ETIOLOGI

PROBLEM/

DS :
DO :
DS :
DO :
DS :
DO :
XV. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS MASALAH
NO

Diagnosa

Tanggal

Tanggal

ditemukan

teratasi

XVI. RENCANA KEPERAWATAN

No No Diagnosa

Tujuan dan Kriteria

Intervensi

Rasional

Nama/TTD

Hasil
1
2
3

XVII.

CATATAN PERKEMBANGAN
No Hari/Tanggal/Jam

No.

Implementasi

Respon

Diagnosa
1

DS
DO
DS
DO

Nama/TTD

DS

DO
DS
DO

I.

EVALUASI
No
1

Hari/Tanggal/Jam

NO Diagnosa

Evaluasi

Nama/Paraf

S:
O:
A:

P:
S:
O:
A:
P:

Denpasar, 20..
Mahasiswa,

()