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 : ..................................................................................................
...................................................................................................
Diagnosa medis : ..................................................................................................

II. 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 ( )
• 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
LLA : ........... cm LK : .......... cm LP : .......... cm
 b. Kulit
.....................................................................................................................................
c. Kepala
.....................................................................................................................................
d. Mata
.....................................................................................................................................
e. 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

XIII. INFORMASI LAIN (mencakup rangkuman kesehatan klien dari gizi, fisioterapis, dll)
XIV. ANALISIS DATA
DATA MASALAH/ PROBLEM PENYEBAB/ ETIOLOGI
DS :
DO :
DS :
DO :
DS :
DO :

XV. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS MASALAH

1. ...
2. ...
3. ...

XVI. RENCANA KEPERAWATAN

No Diagnosa Tujuan dan Kriteria Intervensi Rasional Nama/TTD
Keperawatan Hasil (NOC) (NIC)
1

XVII. CATATAN PERKEMBANGAN

No tanggal No. Jam Implementasi Evaluasi Nama/TTD
Diagnosa
1 S:
O:
A:
P:
2 S:
O:
A:
P:
3 S:
O:
A:
P:

Denpasar, ………20..
Mahasiswa,

(…………………………)