Format PKK Anak Konteks Keluarga
Format PKK Anak Konteks Keluarga
LEMBAR PENGESAHAN
NAMA : ............................................................................................................
NIM : ...........................................................................................................
SEMESTER : ...........................................................................................................
JUDUL : Asuhan Keperawatan Anak ....... Dengan ................................... Di
Puskesmas...........................................................
Mengetahui,
Pembimbing Akademik
(............................................................)
NIK.
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Lampiran 4. Format Cover Laporan
ASUHAN KEPERAWATAN
ANAK ..................... DENGAN ...........................................................
DI PUSKESMAS .............................................................
DISUSUN OLEH:
NAMA : ..............................................
NIM : ..............................................
KELAS : ..............................................
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Lampiran 5. Format Asuhan Keperawatan Anak dalam Konteks Keluarga
i. Genogram
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j. Tipe keluarga :
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k. Kewarganegaraan/ Suku bangsa:
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l. Agama :
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m. Status sosial ekonomi keluarga:
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n. Aktivitas rekreasi keluarga:
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b. Tahap perkembangan keluarga yang belum terpenuhi:
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3. Keadaan lingkungan
a. Karakteristik rumah:
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b. Karakteristik tetangga dan komunitas:
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c. Mobilitas keluarga:
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d. Perkumpulan keluarga dan interaksi dengan masyarakat:
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e. Sistem pendukung keluarga
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4. Struktur keluarga:
a. Pola komunikasi keluarga
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b. Struktur kekuatan keluarga
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c. Struktur peran keluarga
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d. Nilai dan norma keluarga
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5. Fungsi keluarga
a. Fungsi afeksi
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b. Fungsi sosial
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c. Fungsi pelayanan kesehatan
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7. Pemeriksaan fisik
Hasil Pemeriksaan Fisik Anggota Keluarga
Komponen
Kepala
Mata
Telinga
Hidung
Mulut dan
gigi
Leher &
tenggorokan
Dada
Abdomen
Ekstermitas
Kulit
Kuku
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Hasil Pemeriksaan Fisik Anggota Keluarga
Komponen
BB/TB
TD
Nadi
Suhu
Pernapasan
....................... ........................2019
Pembimbing Wahana Praktik, Mahasiswa,
(....................................................) ( ....................................................)
NIP.
9
B. DIAGNOSIS KEPERAWATAN
1. Analisis data
Data Masalah/ Diagnosis Keperawatan
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2. Prioritas Masalah
Kriteria Bobot Pembenaran
Sifat Masalah
Potensial dicegah
Menonjolnya masalah
Skor
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C. RENCANA KEPERAWATAN
DIAGNOSIS TUJUAN KRITERIA EVALUASI
NO. RENCANA INTERVENSI
KEPERAWATAN Umum Khusus Kriteria Standar
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D. IMPLEMENTASI & EVALUASI
No. Dx.
Tanggal Implementasi Evaluasi Paraf
Keperawatan
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Lampiran 6. Daftar Hadir Mahasiswa
NAMA : .......................................................................................................................
NIM : .......................................................................................................................
PUSKESMAS : ........................................................................................................................
` Mengetahui :
Pembimbing Wahana Praktik,
(………………………………………)
14
Lampiran 7 Format Penilaian Sikap
Kategori Nilai
No Sub bagian Ket
Penilaian sikap 1 2 3 4
1. Penulisan data pengkajian
1. Ketelitian 2. Penetapan diagnose keperawatan
3. Prioritas diagnose keperawatan
4. Pemilihan intervensi
5. Implementasi keperawatan
6. Evaluasi
1. Menyampaikan informasi yang benar kepada CI dan pasien
2. Tanggung jawab 2. Melaksanakan askep yang dibuat
3. Pelaksanaan tugas rutin
1. Bertanya kepada CI
3. Keaktifan 2. Belajar melakukan tindakan
3. Melakukan tugas rutin
4. Berpastisipasi dalam diskusi
1. Datang ke lahan (terlambat/tidak)
4. Disiplin 2. Pulang (tepat waktu/tidak)
3. Kelengkapan atribut
4. Kelengkapan pakaian
5. Kepatuhan terhadap peraturan RS
1. Penyampaian informasi kepada pasien tentang:
5. Kejujuran a. Pengobatan
b. Prognosis penyakit
c. Perawatan yang dilaksanakan
2. Penyampaian informasi kepada CI tentang:
a. Tugas rutin
b. Asuhan keperawatan
1. Hormat dan sopan
6. Sikap terhadap 2. Patuh
pembimbing 3. Mampu bekerja sama
1. Memperkenalkan diri
7. Sikap terhadap 2. Menjelaskan maksud tindakan
klien 3. Komunikasi terapeutik
4. Menghormati klien dan keluarga
8. Sikap terhadap 1. Hormat terhadap teman sejawat
teman sejawat 2. Mampu bekerjasama
JUMLAH
………………………………………2019
Pembimbing,
(………………………………………………)
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Lampiran 8. Format Penilaian Penyuluhan Kesehatan
Nama : ....................................................................
NIM : .....................................................................
Ruang Praktek : .....................................................................
SKALA PENILAIAN :
……………………, ………………2019
A : 90 -100
A - :84-89 Pembimbing,
B+ : 78 -83
B : 73 -77
B- : 66-72
(…………………………………………)
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Lampiran 9. Format Penilaian Evaluasi Klinik (Pre Conference)
Nama : ....................................................................
NIM : .....................................................................
Ruang Praktek : .....................................................................
SKALA PENILAIAN :
……………………, ………………2019
A : 90 -100
A - :84-89 Pembimbing,
B+ : 78 -83
B : 73 -77
B- : 66-72
(…………………………………………)
17
Lampiran 10. Format Penilaian Evaluasi Klinik (Post Conference)
Nama : ....................................................................
NIM : .....................................................................
Ruang Praktek : .....................................................................
SKALA PENILAIAN :
……………………, ………………2019
A : 90 -100
A - :84-89 Pembimbing,
B+ : 78 -83
B : 73 -77
B- : 66-72
(…………………………………………)
18
Lampiran 11. Format Penilaian Evaluasi Laporan Pendahuluan
Nama : ....................................................................
NIM : .....................................................................
Ruang Praktek : .....................................................................
SKALA PENILAIAN :
……………………, ………………2019
A : 90 -100
A - :84-89 Pembimbing,
B+ : 78 -83
B : 73 -77
B- : 66-72
(…………………………………………)
19
Lampiran 12. Format Penilaian Evaluasi Laporan Asuhan Keperawatan
Nama : ....................................................................
NIM : .....................................................................
Ruang Praktek : .....................................................................
SKALA PENILAIAN :
……………………, ………………2019
A : 90 -100
A - : 84-89 Pembimbing,
B+ : 78 -83
B : 73 -77
B- : 66-72
(…………………………………………)
20
YAYASAN BANJAR INSAN PRESTASI
AKADEMI KEPERAWATAN INTAN MARTAPURA
PENILAIAN EVALUASI LAPORAN ASUHAN KEPERAWATAN
PRAKTIK KLINIK KEPERAWATAN ANAK
(Khusus diisi oleh Pembimbing Akademik)
Nama : ....................................................................
NIM : .....................................................................
Ruang Praktek : .....................................................................
SKALA PENILAIAN :
……………………, ………………2019
A : 90 -100
A - :84-89 Pembimbing,
B+ : 78 -83
B : 73 -77
B- : 66-72
(…………………………………………)
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Lampiran 13. DAFTAR PENCAPAIAN KOMPETENSI
Paraf
No. Kompetensi Target Hari, Tanggal Pembimbing
Lahan
1 Pemeriksaan Fisik 5
2 Pengisian DDST 2
3 Pengisian KMS 2
6 Memberikan Imunisasi 2
7 Mengikuti Posyandu 1
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