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 : ..................................................................................................
Tanggal MRS : ..................................................................................................
Diagnosa medis : ..................................................................................................

II. KELUHAN UTAMA

1. Saat MRS
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2. Saat ini
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III. RIWAYAT KESEHATAN SAAT INI
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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 : ....................................................................................
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• 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................................................................
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• Trauma lahir : Ada ( ) Tidak ( )
• Narkosis : Ada ( ) Tidak ( )
• Keluarnya urin/ BAB : Ada ( ) Tidak ( )

c. Penyakit yang pernah diderita

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d. Hospitalisasi
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e. Operasi
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f. Injuri/ kecelakaan
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g. Alergi
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h. Imunisasi
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i. Pengobatan
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V. RIWAYAT PERTUMBUHAN
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VI. TINGKAT PERKEMBANGAN (Gunakan Format DENVER II 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 keluarga : .......................................................................
b. Hubungan dengan teman sebaya : .......................................................................
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)
Sebelum sakit
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Saat sakit
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c. Aktifitas
Kemampuan Perawatan Diri 0 1 2 3 4
Makan dan minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi ROM
Ket :
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantungan total
d. Tidur dan istirahat
Sebelum sakit
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Saat sakit
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e. Eliminasi
BAB
Sebelum sakit
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Saat sakit
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BAK
Sebelum sakit
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Saat sakit
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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 : (Composmetis/ Apatis/Somnolen/Supor/Coma)
GCS : verbal:………. Psikomotor:……….Mata :……………..
TD : ...........mmHg Nadi : .......... x/menit RR :...x/menit
BB : ........... kg TB : .......... cm Suhu badan : ......... o C
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
Paru-paru
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Jantung
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i. Abdomen
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j. Genetalia
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k. Ekstrimitas
Atas
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Bawah
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l. Neurologi
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XI. PEMERIKSAAN DIAGNOSTIK PENUNJANG

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XII. TERAPI YANG DIPEROLEH

Nama obat Dosis Rute

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