BukuEvaluasi

StaseKeperawatanAnak

FORMAT PENGKAJIAN
KEPERAWATAN ANAK
PengkajianTanggal
Jam
Bila RS
Tanggal MRS
Jam MRS
Ruang/Kelas
No. RM

Identitas
I

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

Pasien
Nama
Umur
JenisKelamin
Agama
Pendidikan
Pekerjaan
Alamat
DiagnosaMedis

:
:
:
:
:
:
:
:

II Identitas Orang Tua

Keluhan Utama

Riwayat Penyakit Sekarang

..

..

..

..
D

Riwayat Kesehatan Masa Lalu

1 Prenatal
G....P....A...., HPHT.............., taksiran persalinan ...............
Kenaikan BB saat hamil :................................................ kg
Pemeriksaan kehamilan :
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
Imunisasi TT
:
................................................................................................................
................................................................................................................
................................................................................................................
Penyakit yang diderita saat hamil:
................................................................................................................
................................................................................................................
................................................................................................................
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Emosi ibu pada saat hamil:

................................................................................................................
................................................................................................................
................................................................................................................
Sikap ibu terhadap kehamilan
:
................................................................................................................
................................................................................................................
................................................................................................................
Penggunaan Obat
:
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
Perokok
:
................................................................................................................
................................................................................................................
Alkohol
:
................................................................................................................
................................................................................................................
................................................................................................................
2 Intra Natal
Tanggal persalinan
:.........................................................
Pukul
:.........................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
3

Post Natal ( 24jam )

a. APGAR skor
b. BBL
c. PBL
d. LK
e. LD
f. Keadaanbayi

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

Penyakit yang pernahdiderita

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

Hospitalisasi/TindakanOperasi
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
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.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
6

Obat-obatan yang digunakan

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

Allergi
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................

Imunisasi danteslaboratorium
a. Imunisasi
: [ ]Ya
[ ]Tidak
N
O
1.
2.
3.
4.
5.

b.

Jenisimmunisasi

Waktupemberian

Reaksisetelahpemberian

BCG
DPT (I,II,III)
Polio (I,II,III,IV)
Campak
Hepatitis

Tesdarah/screening test yang pernahdilakukan :

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

Riwayat Keluarga
1 Penyakit keluarga
a. Penyakit keturunan
:
................................................................................................................
................................................................................................................
................................................................................................................
b. Kelainan kongenital :
.................................................................................................................
................................................................................................................
................................................................................................................
2

Genogram

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Pengkajian 14 Kebutuhan Dasar Manusia (Virginia Henderson)

1. Pernapasan
a. Lingkar dada
:
b. RR
:
x/mnt
c. Irama
: .................................................................
d. Bentuk dada
: .................................................................
e. Pengembangan dada : .................................................................
f. Batuk
: .................................................................
g. Frekuensi
: .................................................................
h. Perawatan/pengobatan : .................................................................
i. Pola nafas
: .................................................................
j. Alat bantu nafas
: .................................................................
k. Pemakaian otot bantu napas: .................................................................
...............................................................................................................
l. Sesak napas
: .................................................................
.................................................................
.................................................................
m. Pernapasan
: .................................................................
n. Jenis
: .................................................................
o. Suara nafas
: .................................................................
p. Pernapasan cuping hidung
: [ ]Ada
[ ]Tidak
q. Vokal premitus
: .................................................................
r. Sianosis
: .................................................................
s. Kemampuan anak
: .................................................................
2.

Nutrisi dan Cairan

a Riwayat Nutrisi
1 Pemberian ASI
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
2 Pemberiansusu formula
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
3

Polaperubahannutrisitiaptahapusiasampainutrisisaatini
Usia
JenisNutrisi
Lama Pemberian
1 0 6 Bulan
2 6 12 Bulan
3 Saatini

Nutrisi Saat ini

Nafsu makan

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

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Frekuensi
:
x/hari
Porsi makan
: .................................................................
Makanan pantangan : .................................................................
Suplemen/vitamin : .................................................................
Minum
:
cc/hari
Jenis minuman
: .................................................................
Antopometri
BB
: .................................................................
TB
: .................................................................
LILA
: .................................................................
Lingkarperut
: .................................................................
Lingkarkepala
: .................................................................
Bisingusus:
x/mnt
Warnarambut
: .................................................................
Ubun-ubun
: .................................................................
Konjungtiva
: .................................................................
Sklera
: .................................................................
Mukosa
: .................................................................
Tenggorokan
: .................................................................
.................................................................
Turgor kulit
: .................................................................
Bentuk abdomen : .................................................................
Abdomen
: .................................................................
.................................................................
.................................................................
Pembesaran hepar : .................................................................
Pembesaran lien : .................................................................
Kemampuan anak : .................................................................

Eliminasi
1) BAK
a) Frekuensi
:
x/hari
b) Warna
:...............................................................................................
.........................
c) Bau
:...............................................................................................
.........................
d) Kekeruhan
:...............................................................................................
.........................
e) Pembesaran
VU
:..........................................................................................................
..............
f) Nyeri
tekan
:..........................................................................................................
..............
g) Volume
:
cc/hari
h) Penggunaan alat bantu : ..................................................
i) Uretra
:...............................................................................................
.........................
j) Kebersihan genetalia
: ...................................................
k) Gangguan
:...............................................................................................
.........................
l) Kemampuan
anak
:.................................................................................................................
..
2) BAB
a) Frekuensi

x/hari

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b) Warna
:...............................................................................................
.........................
c) Konsistensi
:...............................................................................................
.........................
d) Bau
:...............................................................................................
.........................
e) Kondisianus
:...............................................................................................
.........................
f) Kesulitansaat BAB, jelaskan: ............................................
g) Kemampuananak :.............................................................................................
.....................
3.

Mobilisasi
Kesimetrisanpostur
Rentanggerak
Penggunaanalatbantu
Tonus otot
Kekuatanotot
Kanan
Kiri
Kemampuananak

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

4.

Tidur dan Istirahat

Polatidur
Siang
:..............jam
Malam
: ..............jam
Kebiasaansebelumtidur:....................................................................................................................
Keluhansaattidur
:........................................................................................................................
Kemampuananak
:........................................................................................................................

5.

Berpakaian
Ganti pakaian sehari berapa kali :
Kemampuan anak memilih pakaian:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................

Kemampuan anak memakai pakaian:

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

Kemampuan anak melepaskan pakaian:

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

Kemampuan anak:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
6. Mempertahankan Suhu Tubuh
0
a. Suhu
:
C
b. Kalau anak demam, apa yang dilakukan keluarga:
................................................................................................................................................................
................................................................................................................................................................
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................................................................................................................................................................
c.

Kebiasaan penggunaan kipas angin/AC:

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

d. Kemampuan anak

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

7.

Menjaga kebersihan
Mandi
Frekuensi
:
x/hari
Kemandirian :........................................................................................................................
Cuci rambut
Frekuensi
:
x/hari
Kemandirian :........................................................................................................................
Gosok gigi
Frekuensi
:
x/hari
Kemandirian :........................................................................................................................
Gunting kuku
Frekuensi
:
x/hari
Kemandirian :........................................................................................................................
Kemampuan anak:........................................................................................................................

8.

Menghindari Bahaya
a. Pengertian bahaya lingkungan menurut anak:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
b.

Upaya anak untuk mengindari bahaya lingkungan:

c.

................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Keadaan lingkungan rumah yang berpotensi bahaya:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................

d.

Adat-istiadat/kepercayaan yang mempengaruhi:

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

e.

Upaya orang tua untuk mencegah cedera:

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

f.
9.

Kemampuan anak:.................................................................................................................................

Berkomunikasi
a. Kemampuan anak menyatakan keinginan :
................................................................................................................................................................
................................................................................................................................................................
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................................................................................................................................................................
b. Hambatan anak dalam berkomunikasi:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
c. Kemampuan komunikasi 2 arah:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
d. Artikulasi bisa dimengerti
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
e. Ekspresi sesuai
:........................................................................................................................
f. Kemampuan anak
:........................................................................................................................
10. Bekerja
Kemampuan anak melaksanakan perintah sederhana :
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................

Kemampuan
anak
:.....................................................................................................................
...

11. Bermain
a. Jenis permainan yang disukai
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
b.

Waktu
bermain
:.....................................................................................................................
...
c. Lama bermain
:.....................................................................................................................
...
d. Teman
bermain
:.....................................................................................................................
...
e. Sebutkan beberapa nama teman :
f. Pemanfaatan waktu luang keluarga :
g. Ritual rekreasi bersama keluarga :
h. Kemampuan
anak
:.....................................................................................................................
...
12. Beribadah
Agama
:...............................................................................................
.........................
Waktu ibadah
:.....................................................................................................................
...
Pengajaran/penerapan cara beribadah oleh orang tua :
Inisiatif
beribadah
:.....................................................................................................................
...
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Kemampuan
beribadah:................................................................................................................
........
13. Belajar
Pengetahuan anak tentang konsep sehat-sakit :
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................

Persepsi anak terhadap hospitalisasi :

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

Upaya anak menjaga kesehatan:

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

Kebutuhan informasi anak tentang kesehatan :

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

Kemampuan
anak
:............................................................................................................................
..

Pemeriksaan Indra
Penglihatan (mata)
Pupil
:..........................................................................................................
............................
Refleks
cahaya
:.................................................................................................................................
.....
Visus
:..........................................................................................................
............................
Lapang
pandang
:.................................................................................................................................
.....
Pendengaran (telinga)
Gangguan
pendengaran:......................................................................................................................
......
Penciuman (hidung)
Bentuk
:..........................................................................................................
............................
Gangguan
Penciuman
:..............................................................................................................................
H Refleks Primitif
Moro
:..........................................................................................................
............................
Menoleh
:..........................................................................................................
............................
Menghisap
:..........................................................................................................
............................
Palmar
:..........................................................................................................
............................
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Pattela
:..........................................................................................................
............................
Balbinski
:..........................................................................................................
............................

Sistem Kardiovaskuler
TD
:
mmHg
Nadi
:
x/mnt
Iramajantung
:..........................................................................................................
............................
Bunyijantung
:..........................................................................................................
............................
Letak
ictus
cordis
:.................................................................................................................................
.....
Nyeridada
:..........................................................................................................
............................
Cappilaryrefill :..........................................................................................................
............................
Akral
:..........................................................................................................
............................

Sistem Reproduksi
1. Pengetahuantentangperkembanganreproduksi
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................

Test Diagnostik
1. PemeriksaanLaboratorium
Tanggal :, Jam :..
JenisPemeriksaan

Hasil

Harga Normal

Satuan

Interpretasihasil

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2.

PemeriksaanRadiologi, MRI, USG, EEG, ECG CT Scan:

Tanggal :, Jam :..

JenisPemeriksaan

HasilBacaan

Kesan

Interpretasihasil

TerapiMedis
JenisTerapi
Cairan IV

NamaObat

Dosis

Rute

Obat parenteral

Obat peroral

Obat Topikal

.................., ......../......./.......

(namaperawat)

Program PendidikanProfesiNers FIKES UniversitasRespatiYogyakarta(Unriyo) 11

Fungsi

BukuEvaluasi
StaseKeperawatanAnak

STASE KEPERAWATAN ANAK

PROGRAM PENDIDIKAN PROFESI NERS
UNIVERSITAS RESPATI YOGYAKARTA

ANALISA DATA
Nama klien

: ...

No. Register

Umur

Diagnosa Medis :...

Ruang Rawat :
TGL/JAM
DATA FOKUS

TGL/JA

DATA FOKUS

Alamat

:...

:
ETIOLOGI
PROBLEM

ETIOLOGI

Program PendidikanProfesiNers FIKES UniversitasRespatiYogyakarta(Unriyo) 12

PROBLEM

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TGL/JAM

DATA FOKUS

ETIOLOGI

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PROBLEM

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PRIORITAS DIAGNOSA

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StaseKeperawatanAnak

STASE KEPERAWATAN ANAK

PROGRAM PENDIDIKAN PROFESI NERS
UNIVERSITAS RESPATI YOGYAKARTA

RENCANA TINDAKAN
Nama klien :
Umur
:
Ruang
:
No

Dx.
Keperawatan

Tujuan&KriteriaHasil

No. Register:..
Diagnosa Medis:..
Alamat :.
Intervensi

Rasionalisasi

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Paraf

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STASE KEPERAWATAN ANAK

PROGRAM PENDIDIKAN PROFESI NERS
UNIVERSITAS RESPATI YOGYAKARTA

CATATAN PERKEMBANGAN I
Nama klien :
Umur
:
Ruang
:

N
o
D
x

Tgl/
Jam

Implementasi

No.Register :
Diagnosa Medis: ...
Alamat
:.

Evaluasi

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Paraf

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STASE KEPERAWATAN ANAK

PROGRAM PENDIDIKAN PROFESI NERS
UNIVERSITAS RESPATI YOGYAKARTA

CATATAN PERKEMBANGAN II
Nama klien :
Umur
:
Ruang
:

N
o
D
x

Tgl/
Jam

Implementasi

No.Register
:
Diagnosa Medis: ...
Alamat
:.

Evaluasi

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Paraf

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STASE KEPERAWATAN ANAK

PROGRAM PENDIDIKAN PROFESI NERS
UNIVERSITAS RESPATI YOGYAKARTA

CATATAN PERKEMBANGAN III

Namaklien :
Umur
:
Ruang
:

N
o
D
x

Tgl/
Jam

Implementasi

No.Register
:
DiagnosaMedis: ...
Alamat
:.

Evaluasi

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Paraf

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Pembimbing Klinik
Mahasiswa

Pembimbing Akademik

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