Format Pengkajian Neo Anak
Format Pengkajian Neo Anak
OLEH
NAMA: Heri Saputro, S.Kep., Ns
NIM. 13.07.11.120
LAPORAN PENDAHULUAN
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Diajukan Oleh:
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Mengetahui ,
Kepala Ruangan ………………………..
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Diajukan Oleh:
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Mengetahui ,
Kepala Ruangan ………………………..
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I. BIODATA
A. Identitas Klien
1. Nama/Nama panggilan : ...............................................................................................
2. Tempat tanggal lahir / Usia : ...............................................................................................
3. Jenis Kelamin : ...............................................................................................
4. A g a m a : ...............................................................................................
5. Pendidikan : ...............................................................................................
6. A l a m a t : ...............................................................................................
7. Tanggal masuk : ...............................................................................................
8. Tanggal pengkajian : ...............................................................................................
9. Diagnosa Medik : ...............................................................................................
10. Rencana therapy : ...............................................................................................
B. Identitas Orang Tua
Ayah Ibu
Nama : .................................... Nama : ....................................
Usia : .................................... Usia : ....................................
Pendidikan : .................................... Pendidikan : ....................................
Pekerjaan/Penghasilan : .................................... Pekerjaan/Penghasilan : ....................................
Agama : .................................... Agama : ....................................
Alamat : .................................... Alamat : ....................................
C. Identitas Saudara Kandung
No Nama Usia Hubungan Ket
A. Dasar : B. Ulangan :
BCG : +/- Pada umur : Scar : X mm Pada Umur :
DPT : x Pada umur : Di : Pada Umur :
Polio : x Pada umur : Di : Pada Umur :
Campak : Pada Umur : Di :
5. Riwayat Penyakit Dahulu : (alergi, hospitalisasi, injury, pengobatan dll)
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6. Riwayat Sosial, Ekonomi dan Lingkungan :
Yang Mengasuh…………………………………………………………………………….............
Pola Hubungan …………………………………………………………………………….............
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7. Pemeriksaan Fisik Khusus :
a. Kesan Umum :
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b. Tanda Vital Utama :
Nadi : ........ x/menit, isi dan tegangan : ............... Teratur /tidak *)
Suhu : ........0C
Tekanan Darah : ........ mmHg
Pernafasan : ........ x/menit Tipe : ........................
c. Status Gizi :
Kesimpulan Status Gizi : Gizi lebih, Gizi baik, Gizi kurang, Gizi buruk *)
d. Kulit/integumen :
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e. Kelenjar limpe :
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g. Tulang :
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h. Sendi :
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i. Jantung :
1) Batas Jantung (Jelaskan) : inspeksi, palpasi, perkusi
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2) Suara Jantung :
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j. Paru – paru/pernafasan (Inspeksi, Palpasi, Auskultasi, Perkusi):
Belakang
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l. Anogenital :
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m. Ekstremitas :
Refleks Pathologis
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o. Kepala :
1) Bentuk, rambut, kulit :
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2) Mata :
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Pediatric Nursing Departement, 2016
www.ners.stikesstrada.ac.id
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3) Hidung :
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4) Telinga :
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5) Mulut (dan Gigi):
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6) Pharynx, leher :
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Tanggal:
Tanggal:
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Mahasiswa
(……………………………………..)
ANALISA DATA
Nama Pasien : Ruang :
Umur : Hari/tgl :
Pediatric Nursing Departement, 2016
www.ners.stikesstrada.ac.id
No Data Fokus Etiologi Problem/Masalah
PRIORITAS MASALAH
1. ..............................................................................................................................................................
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Pediatric Nursing Departement, 2016
www.ners.stikesstrada.ac.id
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RENCANA KEPERAWATAN
Nama Pasien : Ruang :
Umur : Hari/tgl :
Diagnosa Tujuan (NOC) Intervensi (NIC)
JL. Manila PLN Sumberece Telp. (0354) 7009713 Fax : (0354) 695130, Email: www.ners.stikesstrada.ac.id
PENGKAJIAN NEONATUS
A. IDENTITAS NEONATUS
Nama Bayi :
Tanggal Lahir : Jam :
Jenis : Laki – Laki / Perempuan
Umur :
Ruang :
Kelahiran : tunggal/kembar, hidup/mati
Tanggal MRS : Jam :
Tanggal Pengkajian : Jam:
Diagnosa medis :
B. IDENTITAS ORANG TUA
Nama Ibu : Nama Ayah :
Umur Ibu : Umur Ayah :
Pekerjaan Ibu : Pekerjaan Ayah:
Pendidikan Ibu : Pendidikan Ayah:
Agama :
Alamat :
Dikirim Oleh :
D. RIWAYAT KEPERAWATAN
1. Riwayat Keperawatan Sekarang :
a. Keluhan utama :
b. Imunisasi :
a. BCG c. Polio……….x d. DPT……………x
b. Campak d. Hepatitis……….x
3. Riwayat Keluarga
Genogram :
5. Pengkajian fisik
a. Tanda – Tanda Vital :
Nadi : x/menit
Suhu : °C
Pernafasan : x/menit, tipe :
CRT :
Tekanan Darah: mmHg
b. Pemeriksaan Fisik
Kulit :
Kepala :
Mata :
Hidung :
Telinga:
Mulut/Lidah :
Leher :
Dada :
- Jantung (Inspeksi, Palpasi, Perkusi, Auskultasi)
Anus :
Genital :
Ektremitas
Refleks ;
a. Sucking (menghisap) :
d. Rooting (mencari) :
e. Moro (kejut)
f. Babinsky :
g. Gallant (punggung) :
h. Swallowing (menelan) :
c. Nilai Apgar
1 Menit 5 Menit 2 Jam
E. PEMERIKSAAN PENUNJANG :
Tgl Tgl
F. TERAPI:
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Mahasiswa
( )
Sumber Informasi :
- Status/rekam medik pasien, Wawancara dengan orang tua, KMS anak
I. IDENTITAS ANAK
Pengkajian di lakukan tanggal .....................................
Nama Anak : ..............................................................................................
TTL : ..............................................................................................
Umur & jenis Kelamin : ..............................................................................................
Anak Ke : ..............................................................................................
II. IDENTITAS ORANG TUA
Ayah Ibu
Nama : ........................................... Nama : ...........................................
Usia : ........................................... Usia : ...........................................
Pendidikan : ........................................... Pendidikan : ...........................................
Pekerjaan : ........................................... Pekerjaan : ...........................................
Agama : ........................................... Agama : ...........................................
Suku : ........................................... Suku : ...........................................
Alamat : ........................................... Alamat : ...........................................
III. ANAMNESA
(1) Keluhan Utama :
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(2) Masalah tumbuh kembang :
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IV. PENGKAJIAN PERTUMBUHAN DAN PERKEMBANGAN
(1) Pertumbuhan
Berat Badan ( BB ) : kg Status Gizi (BB/TB) : s/d SD
Tinggi Badan ( TB ) : cm Lingkar Kepala ( LK ): cm
Contoh Pada
(2) Perkembangan Usia 36 Bulan
1. KUESIONER PRA SKRINING PERKEMBANGAN ( KPSP )
KUISIONER PRA SKRINING PERKEMBANGAN USIA ....36...... BULAN
Tanggal Lahir :
5. Dapatkah anak melempar bola lurus ke arah perut atau dada anda dari jarak 1,5
meter?
6. Ikuti perintah ini dengan seksama. Jangan memberi isyarat dengan telunjuk atau
mata pada saat memberikan perintah berikut ini:
“Letakkan kertas ini di lantai”.
“Letakkan kertas ini di kursi”.
“Berikan kertas ini kepada ibu”.
Dapatkah anak melaksanakan ketiga perintah tadi?
7. Buat garis lurus ke bawah sepanjang sekurangkurangnya 2.5 cm. Suruh anak
menggambar garis lain di samping garis tsb.
8. Letakkan selembar kertas seukuran buku di lantai. Apakah anak dapat melompati
bagian lebar kertas dengan mengangkat kedua kakinya secara bersamaan tanpa
didahului lari?
9. Dapatkah anak mengenakan sepatunya sendiri?
10. Dapatkah anak mengayuh sepeda roda tiga sejauh sedikitnya 3 meter?
Interpretasi hasil yang di dapat dalam pemeriksaan KPSP dengan jumlah jawaban “Ya” yang dinilai
dengan point 10, perkembangan anak sesuai/tidak sesuai dengan tahap perkembangannya ( S )
Interpretasi Hasil :
Tidak ditemukan indikasi Gangguan Pemusatan Perhatian dan Hiperaktivitas (GPPH)
V. ALASAN PENGKAJIAN
No Jenis Pengkajian Alasan
1. Pertumbuhan :
VI. INTERVENSI
No Hasil Pengkajian Intervensi
1. Pertumbuhan :
b. Lingkar Kepala : - .
Hasil ........................
2. Perkembangan :
a. Kuesioner Pra Skrining -
Perkembangan (KPSP)
untuk anak usia 36 bulan :
Interpretasi hasil
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b. Denver Developmental - Anjurkan orang tua ..................
Screening Test (DDST)
Interpretasi hasil :
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c. TDD (Tes Daya Dengar) : - .
Hasil: ........................... ....
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e. Kuesioner MME - .
f. CHAT (Checklist for
Autism in Toddlers)
g. Abbreviated Conners
Ratting Scala ( Conners )
VII. EVALUASI
Mahasiswa
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