Lampiran 3.

Format Lembar Pengesahan

YAYASAN BANJAR INSAN PRESTASI

AKADEMI KEPERAWATAN INTAN MARTAPURA
TAHUN AJARAN 2018/2019

LEMBAR PENGESAHAN
NAMA : ............................................................................................................
NIM : ...........................................................................................................
SEMESTER : ...........................................................................................................
JUDUL : Asuhan Keperawatan Anak ....... Dengan ................................... Di
Puskesmas...........................................................

Mengetahui,
Pembimbing Akademik

(............................................................)
NIK.

1
Lampiran 4. Format Cover Laporan

ASUHAN KEPERAWATAN
ANAK ..................... DENGAN ...........................................................
DI PUSKESMAS .............................................................

DISUSUN OLEH:
NAMA : ..............................................
NIM : ..............................................
KELAS : ..............................................

YAYASAN BANJAR INSAN PRESTASI

AKADEMI KEPERAWATAN INTAN MARTAPURA
TAHUN AJARAN 2018/2019

2
Lampiran 5. Format Asuhan Keperawatan Anak dalam Konteks Keluarga

ASUHAN KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

A. PENGKAJIAN
1. Data umum
a. Nama KK : ...............................................................
b. Umur : ...............................................................
c. Pendidikan KK : ...............................................................
d. Pekerjaan KK : ...............................................................
e. Agama : ...............................................................
f. Suku : ...............................................................
g. Alamat : ...............................................................
h. Komposisi keluarga :
Jenis
No Nama Hub dg KK Umur Pendidikan Pekerjaan
Kelamin

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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2. Riwayat tahap perkembangan keluarga

a. Tahap perkembangan keluarga inti:
...................................................................................................................................................
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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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6. Stres dan koping keluarga

a. Stresor jangka pendek dan jangka panjang
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b. Kemampuan keluarga berespon terhadap stresor
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c. Strategi koping keluarga yang digunakan

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d. Strategi adaptasi yang disfungsi
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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

8. Harapan keluarga terhadap asuhan keperawatan

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
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....................... ........................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

Kemungkinan untuk diubah

Potensial dicegah

Menonjolnya masalah

Skor

3. Rumusan diagnosis keperawatan

a. ........................................................................................................................................
........................................................................................................................................
b. ........................................................................................................................................
........................................................................................................................................
c. ........................................................................................................................................
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d. ........................................................................................................................................
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e. ........................................................................................................................................
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C. RENCANA KEPERAWATAN
DIAGNOSIS TUJUAN KRITERIA EVALUASI
NO. RENCANA INTERVENSI
KEPERAWATAN Umum Khusus Kriteria Standar

12
D. IMPLEMENTASI & EVALUASI
No. Dx.
Tanggal Implementasi Evaluasi Paraf
Keperawatan

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Lampiran 6. Daftar Hadir Mahasiswa

YAYASAN BANJAR INSAN PRESTASI

AKADEMI KEPERAWATAN INTAN MARTAPURA
PRESENSI KEHADIRAN MAHASISWA PRAKTIK KEPERAWATAN
ANAK DALAM KONTEKS KELUARGA

NAMA : .......................................................................................................................
NIM : .......................................................................................................................
PUSKESMAS : ........................................................................................................................

Datang Pulang Paraf

No. Hari / Tanggal Ket
Jam Paraf Jam Paraf Pembimbing
1

` Mengetahui :
Pembimbing Wahana Praktik,

(………………………………………)

14
Lampiran 7 Format Penilaian Sikap

YAYASAN BANJAR INSAN PRESTASI

AKADEMI KEPERAWATAN INTAN MARTAPURA
FORMAT PENILAIAN SIKAP
PRAKTIK KLINIK KEPERAWATAN ANAK DALAM KONTEKS KELUARGA
Nama mahasiswa : ...............................................................................................................................
NIM : ............................................................................................................. ..................
Puskesmas : ..............................................................................................................................

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,

(………………………………………………)

15
Lampiran 8. Format Penilaian Penyuluhan Kesehatan

YAYASAN BANJAR INSAN PRESTASI

AKADEMI KEPERAWATAN INTAN MARTAPURA
PENILAIAN PENYULUHAN /PENDIDIKAN KESEHATAN
PRAKTIK KLINIK KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

Nama : ....................................................................
NIM : .....................................................................
Ruang Praktek : .....................................................................

NO. ASPEK YANG DINILAI BOBOT NILAI

I Persiapan
a. Identifikasi Masalah 10
b. Membuat SAP 10
c. Penggunaan Media 10
II Pelaksanaan
a. Melakukan pendekatan dengan tepat 15
b. Menjelaskan maksud dan tujuan 15
c. Penggunaan bahasa 10
d. Mampu membangkitkan minat/motivasi peserta 10
III Evaluasi
a. Peserta kooperatif selama kegiatan 5
b. Peserta memahami isi penyuluhan 5
c. Peserta memiliki motivasi untuk mengikuti kegiatan 5
penyuluhan
d. Peserta mengajukan pertanyaan sesuai dengan materi 5
yang diberikan
Total

SKALA PENILAIAN :
……………………, ………………2019
A : 90 -100
A - :84-89 Pembimbing,
B+ : 78 -83
B : 73 -77
B- : 66-72

(…………………………………………)

16
Lampiran 9. Format Penilaian Evaluasi Klinik (Pre Conference)

YAYASAN BANJAR INSAN PRESTASI

AKADEMI KEPERAWATAN INTAN MARTAPURA
PENILAIAN EVALUASI KLINIK PRE CONFERENCE
PRAKTIK KLINIK KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

Nama : ....................................................................
NIM : .....................................................................
Ruang Praktek : .....................................................................

NO. ASPEK YANG DINILAI BOBOT NILAI

1 Kesiapan dalam pre conference 10
2 Mengemukakan pendapat selama conference 25
3 Pengetahuan tentang rencana keperawatan meliputi: 25
identifikasi masalah, identifikasi tujuan, identifikasi
intervensi
4 Berperan secara aktif dalam diskusi 10
5 Menunjukkan pola pikir aktif 20
6 Perilaku dan keterampilan secara optimal 10
Total

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)

YAYASAN BANJAR INSAN PRESTASI

AKADEMI KEPERAWATAN INTAN MARTAPURA
PENILAIAN EVALUASI KLINIK POST CONFERENCE
PRAKTIK KLINIK KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

Nama : ....................................................................
NIM : .....................................................................
Ruang Praktek : .....................................................................

NO. ASPEK YANG DINILAI BOBOT NILAI

1 Kesiapan dalam post conference 10
2 Mengemukakan pendapat selama conference 25
3 Pengetahuan tentang rencana keperawatan meliputi: 25
identifikasi masalah, identifikasi tujuan, identifikasi
intervensi
4 Berperan secara aktif dalam diskusi 10
5 Menunjukkan pola pikir aktif 20
6 Perilaku dan keterampilan secara optimal 10
Total

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

YAYASAN BANJAR INSAN PRESTASI

AKADEMI KEPERAWATAN INTAN MARTAPURA
PENILAIAN EVALUASI LAPORAN PENDAHULUAN
PRAKTIK KLINIK KEPERAWATAN ANAK DALAM KONTEKS KELUARGA
(Khusus diisi oleh Pembimbing Akademik)

Nama : ....................................................................
NIM : .....................................................................
Ruang Praktek : .....................................................................

NO. ASPEK YANG DINILAI BOBOT NILAI

I Pendahuluan
a. Kelengkapan definisi, etiologi, manifestasi klinis, 10
patofisiologi
b. Pemeriksaan penunjang 5
c. Kelengkapan diagnosis keperawatan 10
d. Kelengkapan tindakan keperawatan 10
II Pengkajian
a. Pengumpulan data 10
b. Diagnosis keperawatan 10
III Perencanaan
a. Prioritas masalah 5
b. Tujuan dan kriteria hasil 10
c. Rencana keperawatan 10
d. Evaluasi keperawatan 10
IV Daftar Referensi 10
Total 100

SKALA PENILAIAN :
……………………, ………………2019
A : 90 -100
A - :84-89 Pembimbing,
B+ : 78 -83
B : 73 -77
B- : 66-72

(…………………………………………)

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Lampiran 12. Format Penilaian Evaluasi Laporan Asuhan Keperawatan

YAYASAN BANJAR INSAN PRESTASI

AKADEMI KEPERAWATAN INTAN MARTAPURA
PENILAIAN EVALUASI LAPORAN ASUHAN KEPERAWATAN
PRAKTIK KLINIK KEPERAWATAN ANAK
(Khusus diisi oleh Pembimbing Wahana Praktik)

Nama : ....................................................................
NIM : .....................................................................
Ruang Praktek : .....................................................................

NO. ASPEK YANG DINILAI BOBOT NILAI

I Pengkajian Keperawatan
a. Pengumpulan data 25
b. Kelengkapan Data 25
c. Kesesuaian data dengan kondisi pasien 25
d. Kemampuan menemukan masalah kesehatan pada pasien 25
Total 100

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 : .....................................................................

NO. ASPEK YANG DINILAI BOBOT NILAI

I Analisis Data
a. Pengumpulan data 10
b. Diagnosis keperawatan 10
II Perencanaan
a. Prioritas Masalah 10
b. Tujuan dan kriteria hasil 10
c. Rencana keperawatan 10
III Implementasi
a. Prioritas masalah 10
b. Objektifitas 10
IV Evaluasi
a. Reassessment 10
b. Interpretasi 10
c. Planning 10
Total 100

SKALA PENILAIAN :
……………………, ………………2019
A : 90 -100
A - :84-89 Pembimbing,
B+ : 78 -83
B : 73 -77
B- : 66-72

(…………………………………………)

21
Lampiran 13. DAFTAR PENCAPAIAN KOMPETENSI

DAFTAR PENCAPAIAN KOMPETENSI

PKK KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

Paraf
No. Kompetensi Target Hari, Tanggal Pembimbing
Lahan
1 Pemeriksaan Fisik 5

2 Pengisian DDST 2

3 Pengisian KMS 2

4 Pengisian dan penilaian MTBS 2

5 Perhitungan status gizi pada anak 2

6 Memberikan Imunisasi 2

7 Mengikuti Posyandu 1

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