ASUHAN KEPERAWATAN PADA ANAK.................

DENGAN......................................................
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Nama Mahasiswa : ..............................................

NIM : ..............................................
Tempat Praktek : ..............................................
Tanggal Pengkajian : ..............................................
Tanggal Praktek : ..............................................

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.tlp : ..............................................
Tanggal MRS : ..............................................
Diagnosa Medis : ..............................................

II. KELUHAN UTAMA :

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III. RIWAYAT KESEHATAN SAAT INI :

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IV. RIWAYAT KESEHATAN MASALALU
a. Prenatal
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 :
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 Cara melahirkan :
( ) pervaginam normal ( ) SC
( ) vakum ekstasion ( ) lainnya...........................
 Tempat melahirkan :
( ) rumah sakit ( ) rumah bersalin
( ) rumah ( ) lainnya........................
Post natal
 Usaha nafas : ( ) dengan bantuan ( ) tanpa bantuan
 Kebutuhan resusitasi :
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 APGAR score :
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 Bayi langsung menangis : ( ) ya ( ) tidak
 Tangisan bayi : kuat/lemah/lainnya(sebutkan)....................
 Obat-obatan yang diberikan setelah lahir :
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 Trauma lahir : ( ) ada ( ) tidak
 Narkosis : ( ) ada ( ) tidak
 Keluarnya urine/BAB : ( ) ada ( ) tidak
a. Penyakit yang pernah di deritanya
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b. Hospitalisasi
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c. Operasi
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d. Injuri/kecelakaan
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e. Alergi
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f. Imunisasi
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g. Pengobatan
Nama Obat Dosis Rute Indikasi
V. RIWAYAT PERTUMBUHAN
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VI. TINGKAT PERKEMBANGAN (Gunakan format Denver dan Lampirkan)
a. Sosial
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b. Motorik halus
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c. Bahasa
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d. Motorik kasar
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VII. RIWAYAT SOSIAL

a. Hubungan dengan anggota keluarganya :
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b. Hubungan dengan teman sebayanya :
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VIII. RIWAYAT KELUARGA

a. Sosial ekonomi :
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b. Lingkungan rumah :
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c. Penyakit keluarga :
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d. Genogram :
IX. POLA KESEHATAN
a. Pemeliharaan dan persepsi kesehatan :
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b. Nutrisi ( makanan dan cairan ) :
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c. Aktifitas :
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d. Tidur dan istirahat :
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e. Eliminasi :
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f. Pola hubungan :
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g. Kognitif :
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h. Konsep diri :
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i. Seksual :
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j. Nilai :
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X. PEMERIKSAAN FISIK (Inspeksi-Auskultasi)

a. Keadaan Umum : ...........................................................................................
Tingkat kesadaran : ...........................................................................................
TD : ............./.................mmHg Nadi : .................. x/menit
RR : .................... x/menit Suhu : ..................... C
BB : .................. kg Tinggi : .....................cm
LLA : ..................cm LK :..............cm LP :...............cm

b. Kepala
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c. Mata
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d. Telinga
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e. Hidung
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f. Mulut
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g. Leher
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h. Dada
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i. Paru-paru
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j. Jantung
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k. Abdomen
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l. Genetalia
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m. Ekstremitas
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n. Neurologi
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XI. PEMERIKSAAN DIGNOSTIK PENUNJANG

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XII. TERAPI YANG DIPEROLEH

Nama Obat Dosis Rute Indikasi

XIII. INFORMASI LAIN (Mencakup rangkuman kesehatan klien dari gizi,

fisioterapis, dll)
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XIV. ANALISA DATA
SIGN & SYMPTON ETIOLOGI PROBLEM
XV. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS
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 XVI. RENCANA KEPERAWATAN
No. No. Tujuan dan kriteria Intervensi Rasional Nama
Dx hasil dan TTD
 XVII. CATATAN PERKEMBANGAN
No. Hari/tgl/jam No. Implementasi Respon Nama
Dx dan
TTD
 XVIII. EVALUASI KEPERAWATAN
No. Hari/jam/tanggal Diagnosa Evaluasi Nama dan
TTD