Format Askep Anak
Format Askep Anak
DI RUANG.....................................................RS.......................................................
IDENTITAS PASIEN
NAMA PASIEN:
PENANGGUNG JAWAB:
TANGGAL LAHIR :
AGAMA:
NO.RM:
PEKERJAAN ORTU:
TANGGAL PENGKAJIAN:
JAM PENGKAJIAN:
RIWAYAT KESEHATAN PASIEN
KELUHAN UTAMA : ⧠ STATE 1 ⧠ STATE 2 ⧠ STATE 3 ⧠ STATE 4 ⧠ STATE 5
Ket: STATE 1: Eyes Closed, regular respiration, No Movement
STATE 2: Eyes Closed, Irregular respiration, No Movement
STATE 3: Eyes Opened, No Gross Movement
STATE 4: Eyes Opened, No Gross Movement, No Crying
STATE 5: Eyes Opened or Closed, Crying
RIWAYAT PENYAKIT SEKARANG
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RIWAYAT PENYAKIT DAHULU
Pernah menderita penyakit :……………………………………………….pada
umur:
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Pernah dirawat di RS:
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Obat-obatan yang pernah digunakan :
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Tindakan
(operasi):
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Alergi:
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Kecelakaan:
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Imunisasi : ⧠ polio ⧠ HB0
RIWAYAT KEHAMILAN
RIWAYAT PENYAKIT
KELUARGA:
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GENOGRAM:
KEADAAN UMUM
TANDA-TANDA VITAL : Suhu.......OC, Nadi :...........x/mnt (reguler/ireguler), (kuat/lemah) (dangkal/dalam),
Respirasi :..........x/mnt , Tekanan darah :..............mmHg
ANTROPOMETRI:BB:………gr,TB……….cm,LK…….cm,LILA…….cm,LP……cm, LD……cm
KESADARAN : ⧠ Kompos mentis ⧠ Sopor ⧠ Letargis ⧠ Somnolen ⧠ Koma
PENGKAJIAN SISTEM
SISTEM FONTANEL : ⧠DATAR ⧠CEMBUNG ⧠ CEKUNG ⧠TERTUTUP ⧠ CHEPAL
PERSYARAFAN HEMATOM ⧠ CAPUT SUCCEDANUM
SUTURA : ⧠ MOLASE ⧠ TIDAK
MATA :⧠ REFLEK CAHAYA ⧠ TIDAK
REFLEK TONIX NECK : ⧠ ADA ⧠ TIDAK
REFLEK MORO: ⧠ ADA ⧠ TIDAK
REFLEK BABINSKY: ⧠ ADA ⧠ TIDAK
MENINGOCELE: ⧠ ADA ⧠ TIDAK
SPINA BIFIDA: ⧠ ADA ⧠ TIDAK
TERPASANG EVD/SHUNT : ⧠ TIDAK ⧠ YA
Masalah lain: ………………………….
TOTAL
DATA DIAGNOSTIK
Laboratorium:
Radiologi
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Lain -
Lain
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KEBUTUHAN EDUKASI
o Apa yang keluarga ketahui tentang penyakit anak:
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o Informasi apa yang ingin yang diketahui/yang diperlukan oleh keluarga
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Analisa Data
No Data Clinical Pathway Etiologi Masalah
DS:
DO:
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Umur : No CM :
No Hari/Tgl/Jam Dx. Kep Tujuan dan kriteria hasil Intervensi Rasional Paraf
DI RUANG.....................................................RS.......................................................
IDENTITAS PASIEN
NAMA PASIEN :
PENANGGUNG JAWAB :
TANGGAL LAHIR :
AGAMA :
NO.RM :
PEKERJAAN ORTU :
TANGGAL PENGKAJIAN :
JAM PENGKAJIAN :
RIWAYAT KESEHATAN PASIEN
KELUHAN
UTAMA:
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RIWAYAT PENYAKIT SEKARANG
:
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RIWAYAT PENYAKIT DAHULU
1. Pernah menderita penyakit :……………………………………………….pada
umur:
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2. Pernah dirawat di RS:
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3. Obat-obatan yang pernah digunakan :
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4. Tindakan
(operasi):
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5. Alergi:
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6. Kecelakaan:
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7. Imunisasi
:
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Jenis immunisasi Waktu pemberian Frekuensi Reaksi setelah pemberian
DPT (I,II,III)
Polio (I,II,III,IV)
Campak
Hepatitis
RIWAYAT KEHAMILAN
1. Kehamilan :
a. Gestasi : ⧠Prematur , ⧠Fullterm , ⧠ Postmatur .
b. Penyakit selama hamil: ⧠DM , ⧠Hipertensi , ⧠Pendarahan , ⧠Lain-lain: ……
c. Obat yang dikonsumsi selama hamil: ⧠Fe , ⧠Vitamin , ⧠Lain-lain : ……………
d. Imunisasi TT: ⧠ Ya , ………….. kali, ⧠ Tidak .
2. Intra Natal / Proses Persalinan
a. Lama Proses Persalinan :⧠ <12 jam, ⧠>12 jam , ⧠> 24 jam.
b. Yang Menolong Persalinan : ⧠dukun beranak, ⧠ Bidan , ⧠Dokter .
c. Penyulit Persalinan :⧠ Pendarahan banyak , ⧠ Plasenta Ress , ⧠ Lain-lain,………………..
d. Kelainan/ masalah : …………………………………………………………………………
3. Post Natal
a. Berat badan lahir : gram, PB : cm, LK : cm, LD : cm.
b. Kondisi waktu lahir : ⧠Langsung menangis , ⧠Tidak langsung menangis
c. Kelainan kongenital : ⧠ ya,……………………….⧠ tidak
d. Apgar score : ……………………………………………………………………………………
RIWAYAT PENYAKIT
KELUARGA:
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GENOGRAM:
KEADAAN UMUM
TANDA-TANDA VITAL : Suhu.......OC, Nadi :...........x/mnt (reguler/ireguler), (kuat/lemah) (dangkal/dalam),
Respirasi :..........x/mnt , Tekanan darah :..............mmHg
ANTROPOMETRI:BB:……………gr,TB………..cm,LK…….cm,LILA……cm,LP……cm, LD……….cm
KESADARAN : ⧠ Kompos mentis ⧠ Sopor ⧠ Letargis ⧠ Somnolen ⧠ Koma
⧠ Pasien sadar/mengenal angka (Numeric Rating Scale),
Skor Nyeri:
Skor Nyeri:
Ya 2
Skor total
Resiko rendah
Resiko tinggi
Keterangan :
*) penyakit yang beresiko terjadi gangguan gizi diantaranya : dirawat di HCU/ICU, penurunan kesadaran,
kegawatan abdomen (perdarahan, ileus, peritonitis, asites masif, tumor intra abdomen besar, post operasi),
gangguan pernapsan besat, keganasan dengan komplikasi, gagal jantung, gagal ginjal kronik, gagal hati, diabetes
melitus, atau kondisi sakit berat lain
Skor ≥ 2 : resiko tinggi, perlu asesment lebih lanjut oleh dietisien dan/ atau dokter divisi gizi
PENGKAJIAN PSIKOLOGIS
REAKSI HOSPITALISASI ⧠ Takut Nyeri ⧠ Takut Berpisah Dengan Ortu
⧠ Hilang Kontrol
13 – 14 = resiko sedang
DATA DIAGNOSTIK
Laboratorium:
Tanggal No Jenis pemeriksaan Hasil/satuan Nilai normal Interpretasi hasil
Radiologi
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KEBUTUHAN EDUKASI
Apa yang keluarga ketahui tentang penyakit anak:
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Informasi apa yang ingin yang diketahui/yang diperlukan oleh keluarga
:
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Siapa dari keluarga yang akan ikut terlibat dalam perawatan anak
selanjutnya:
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ANALISA DATA
Clinical
No Tgl Data Etiologi Masalah
Pathway
Diagnosa Keperawatan
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Umur : No CM :
No Hari/Tgl/Jam Dx. Kep Tujuan dan kriteria hasil Intervensi Rasional Paraf