KUMPULAN TUGAS PRAKTIK PROFESI NERS

KEPERAWATAN ANAK

Disusun oleh

NAMA : ELIS TRI WULANDARI

NIM : P27220019265

PROGRAM STUDI PROFESI NERS

POLTEKKES SURAKARTA SURAKARTA
TAHUN AKADEMIK 2017/2018
 DAFTAR KETERAMPILAN KLINIK
KEPERAWATAN ANAK

Nama mahasiswa : Kelas :

NIM : Tempat Praktik :

DENGAN
NO KETRAMPILAN MELIHAT MANDIRI
BIMBINGAN
Komunikasi terapeutik pada
1
bayi/anak/keluarga
Evaluasi status nutrisi dengan antropometri
2
(Z- Score) dan NCHS
3 Pemeriksaan Denver II

4 Pemeriksaan Fisik
Pemberian oksigen pada bayi ( nasal kanul,
5
masker dan head box)
6 Perawatan ventilator pada bayi dengan RDS
7 Penilaian ikterus bayi (Kramer Test)
8 Pemasangan dan memonitor cairan infus
9 Pengambilan Spesimen
a. Darah
b. Urine
c. Sputum
10 Pemasangan NGT/OTG
11 Pemberian makan melalui NGT/OTG
12 Pemberian obat
a. Intravena
b. Intramuskuler
c. Subkutan
d. Salep topical
13 Kompres hangat dan kompres kejang demam
14 Fisioterapi Dada
15 Batuk Efektif
16 Pemasangan Skorstin
17 Perawatan kolostomi

18 Perawatan infus pump dan syring pump

19 Melakukan Rumple lead test

20 Pengukuran tingkat edema / asites pada anak
21 Menghitung balance cairan
22 Pertolongan pertama anak kejang
23 Melakukan EKG pada anak
24 Pendidikan kesehatan tumbuh kembang anak
Pendidikan kesehatan anak dengan
25
kegawatan
26 Pendidikan kesehatan nutrisi pada anak

27 Melakukan terapi bermain

28 Melakukan anamnesa dehidrasi pada anak

Melakukan anamnesa dengan pendekatan

29
MTBS

30 Melakukan perawatan tali pusat

31 Melakukan pijat bayi

32 Melakukan immunisasi

33 Persiapan dan perawatan pasca :

a. Lumbal Pungsi

b. Rontgen

c. Colon In Loop

d. Pungsi Pleura

Nilai : Jumlah Pencapaian Target Ketrampilan x 100

33
Surakarta, __________________
Pembimbing Klinik

______________________
 FORMAT LAPORAN KASUS ASUHAN KEPERAWATAN

ASUHAN KEPERAWATAN
PADA An/By ……. DENGAN ...............................................
DI RUANG ……...........................RS …………………………….

Tgl/Jam MRS : ……………………………..

Tanggal/Jam Pengkajian : ……………………………..
Metode pengkajian :.……………………………..
Diagnosa Medis : ……………………………..
No. Registrasi : ……………………………..
I. Kasus Asuhan Keperawatan
A. Pengkajian
1. IDENTITAS KLIEN
a. Nama : ................................................................
b. Tempat/ tgl lahir: ................................................................
c. Umur : ................................................................
d. Pendidikan : ................................................................
e. Alamat : ................................................................
f. Agama : ................................................................
g. Nama Ayah/Ibu: ................................................................
h. Pekerjaan ayah: ................................................................
i. Pekerjaan ibu : ................................................................
j. Pendidikan ayah: ................................................................
k. Pendidikan ibu: ................................................................
l. Agama : ................................................................
m. Alamat : ................................................................
n. Suku bangsa : ................................................................
2. KELUHAN UTAMA
....................................................................................................................................
....................................................................................................................................
3. RIWAYAT PENYAKIT SEKARANG
a. Munculnya keluhan
1). tanggal munculnya keluhan
........................................................................................................................
2). waktu munculnya keluhan (perlahan atau tiba-tiba)
........................................................................................................................
3). faktor presipitasi dan predisposisi (perubahan emosional, kelelahan,
kehamilan, ligkungan, toksin, alergen, infeksi dll)
........................................................................................................................
........................................................................................................................
b. Karakteristik ( PQRST)
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
c. Masalah sejak muncul keluhan
1). insiden
- serangan mendadak tunggal
..................................................................................................................
- kejadian mendadak berulan
..................................................................................................................

- kejadian sehari-hari
..................................................................................................................

- kejadian periodic
..................................................................................................................

2). perkembangan (membaik, memburuk, tidak berubah)

......................................................................................................................
3). effect dari pengobatan
......................................................................................................................
4. RIWAYAT MASA LAMPAU
a. Prenatal
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
b. Natal
..............................................................................................................................
..............................................................................................................................
c. Post natal
..............................................................................................................................
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d. Penyakit waktu kecil
..............................................................................................................................
..............................................................................................................................
e. Pernah dirawat di RS
..............................................................................................................................
f. Obat-obatan yang digunakan
..............................................................................................................................
..............................................................................................................................
g. Alergi
..............................................................................................................................
h. Kecelakaan
..............................................................................................................................
i. Immunisasi
..............................................................................................................................
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5. RIWAYAT KELUARGA (disertai genogram)
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
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....................................................................................................................................
GENOGRAM

6. RIWAYAT SOSIAL
a. Yang mengasuh dan alasannya
..............................................................................................................................
..............................................................................................................................
b. Pembawaan anak secara umum
..............................................................................................................................
..............................................................................................................................

c. Lingkungan rumah
..............................................................................................................................
..............................................................................................................................
7. KEADAAN KESEHATAN SAAT INI (dari rumah sampai saat dikaji)
a. Diagnosa medis :
..............................................................................................................................
b. Tindakan operasi :
..............................................................................................................................
c. Obat-obatan :
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
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d. Tindakan keperawatan
..............................................................................................................................
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e. Hasil laboratorium
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 f. Hasil rontgen
..............................................................................................................................
g. Data tambahan
..............................................................................................................................
..............................................................................................................................
8. PENGKAJIAN POLA FUNGSIONAL MENURUT GORDON
a. Pola persepsi kesehatan dan manajemen kesehatan
1). status kesehatan anak sejak lahir :
........................................................................................................................
........................................................................................................................
2). pemeriksaan kesehatan secar rutin :
........................................................................................................................
3). panyakit-penyakit yang menyebabkan anak absen dari sekolah :
........................................................................................................................
4). praktek pencegahan kesehatan (pakaian, mengganti popok, dll)
........................................................................................................................

5). apakah orang tua merokok? didekat anak?

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

6). mainan anak/ bayi (aman?), keamanan kendaraan?

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

7). praktek keamanan orang tua (produk rumah tangga, menyimpan obat-
obatan, dll)
........................................................................................................................

b. Pola nutrisi-metabolik
1). pemberian ASI/ PASI, perkiraan frekuensi dan jumlah minum, kekuatan
menghisap (bagi bayi) :
........................................................................................................................
........................................................................................................................

2). selera makan, makanan yang disukai/ tidak disukai :

........................................................................................................................
........................................................................................................................
 3). masukan makanan selama 24 jam? makanan tambahan? vitamin?
........................................................................................................................
........................................................................................................................
4). kebiasaan makan?
........................................................................................................................
5). alat makan yang digunakan di rumah
........................................................................................................................
6). berat badan lahir? berat badan saat ini?
........................................................................................................................
........................................................................................................................
7). masalah kulit : rash, lesi dll
........................................................................................................................
8). status nutrisi orang tua (khususnya ibu, apakah ada masalah?)
........................................................................................................................
........................................................................................................................
c. Pola eliminasi
1). pola defekasi (gambaran: frekuensi, kesulitan, kebiasaan, ada darah/tdk)
........................................................................................................................
2). mengganti pakaian dalam/ diapers (bagi bayi)
........................................................................................................................
3). pola eliminasi urin (gambaran: berapa kali popok basah/hari, perkiraan
jumlah, kekuatan keluarnya urin, bau, warna)
........................................................................................................................
4). apakah ada masalah dengan pola eliminasi orang tua?
........................................................................................................................
d. Pola aktivitas-latihan
1). kebiasaan mandi (kapan, dimana, bagaimana, menggunakan sabun apa)
.......................................................................................................................
........................................................................................................................
........................................................................................................................
2). kebersihan rutin (pakaian dll)
........................................................................................................................
.......................................................................................................................
 3). aktivitas sehari-hari (menghabiskan hari-hari dirumah, bermain, tipe
mainan yang digunakan, teman bermain, penampilan saat anak bermain,
dll)
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
4). level kekuatan anak/bayi secara umum, toleransi (giat, diam)
........................................................................................................................
........................................................................................................................

5). persepsi anak terhadap kekuatan dari segi aktivitas (kuat, lemah)
........................................................................................................................
6). kemampuan kemandirian anak (mandi, makan, toileting, berpakaian dll)
........................................................................................................................
........................................................................................................................

7). bagaimana aktivitas pola pemeliharaan anak, pemeliharaan rumah oleh

orang tua?
........................................................................................................................
........................................................................................................................

e. Pola istirahat-tidur
1). pola istirahat/ tidur anak, perkiraan jam jam dll
........................................................................................................................
2). perubahan pola istirahat, mimpi buruk, noctoria?
........................................................................................................................
3). posisi tidur anak? gerakan tubuh?
........................................................................................................................
4). bagaimana pola tidur orang tua?
........................................................................................................................
f. Pola persepsi-kognitif
1). responsiveness anak secara umum
........................................................................................................................
........................................................................................................................
 2). respon anak untuk bicara, sentuhan, suara, objek?
........................................................................................................................
3). apakah anak mengikuti objek dengan matanya? respon untuk meraih
mainan?
........................................................................................................................
4). vokal suara, pola bicara, kata-kata, kalimat?
........................................................................................................................
5). gunakan stimulasi : bicara, mainan, dll
........................................................................................................................
6). kemampuan anak untuk mengatakan nama, waktu, alamat, nomor telepon
dll
........................................................................................................................
7). kemampuan anak untuk mengidentifikasi kebutuhan: lapar, haus, nyeri,
tidak nyaman?
........................................................................................................................
8). Apakah ada masalah pada orang tua: penglihatan, pendengaran, sentuhan,
kesulitan membuat keputusan?
........................................................................................................................
g. Pola persepsi diri-konsep diri
1). status mood bayi/ anak (irritabilitas)
........................................................................................................................
2). pemahaman anak terhadap identitas diri, kompetensi, dll
Anak/bayi:
a. status mood?
..................................................................................................................
b. banyak teman/ seperti yang lain?
..................................................................................................................
c. persepsi diri?
..................................................................................................................
d. kesepian?
..................................................................................................................
e. takut?
..................................................................................................................
 Orang tua:
a. persepsi diri sebagai orang tua?
..................................................................................................................
.................................................................................................................
b. pendapat umum tentang identitas, kompentensi?
..................................................................................................................
..................................................................................................................
h. pola peran-hubungan
a. struktur keluarga
..................................................................................................................
..................................................................................................................
..................................................................................................................
b. masalah/stressor keluarga
..................................................................................................................
c. interaksi antara anggota keluarga dan anak
..................................................................................................................
..................................................................................................................
d. respon anak/ bayi terhadap perpisahan
..................................................................................................................

e. anak: ketergantungan?
.................................................................................................................
f. anak: pola bermain?
..................................................................................................................
..................................................................................................................
g. anak: temper tantrums? masalah disiplin? penyesuaian sekolah?
..................................................................................................................
..................................................................................................................
h. orang tua: peran ikatan? kepuasan? pekerjaan/social/ hubungan
perkawinan?
..................................................................................................................
..................................................................................................................
i. Pola seksualitas
a. perasaan sebagai lali-laki/perempuan?
..................................................................................................................
b. pertanyaan seputar seksualitas? bagaimana respon orang tua? (tidak tahu,
malu, acuh, perubahan seksualitas?
..................................................................................................................
c. orang tua: riwayat reproduksi, ada masalah dengan kepuasan seksual?
..................................................................................................................
..................................................................................................................
j. Pola koping-toleransi terhadap stress
a. apakah yang menyebabkan stres pada anak? tingkat stress? toleransi?
..................................................................................................................
..................................................................................................................
b. pola penanganan masalah? support system?
..................................................................................................................
..................................................................................................................
k. Pola nilai-keyakinan
a. perkembangan moral anak, pemilihan perilaku, komitmen?
..................................................................................................................
..................................................................................................................

b. keyakinan akan kesehatan, keyakinan agama

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

c. orang tua: sesuatu yang bernilai dalam hidupnya (spirituality) semangat

untuk masa depan? keyakinan akan kesembuhan, dampak penyakit dan
tujuan?
..................................................................................................................
..................................................................................................................
9. PEMERIKSAAN FISIK
a. keadaan umum :
.................................................................................................................

b. Tanda vital
..................................................................................................................
..................................................................................................................
c. TB/BB
..................................................................................................................
d. Lingkar kepala
..................................................................................................................
e. Mata
..................................................................................................................
f. Hidung
..................................................................................................................
g. Mulut
..................................................................................................................
h. Telinga
.................................................................................................................
i. Tengkuk/leher
..................................................................................................................
j. Dada
.................................................................................................................
k. Jantung
..................................................................................................................
l. Paru-paru
..................................................................................................................
m. Abdomen
..................................................................................................................
n. Punggung
..................................................................................................................
o. Genetalia
..................................................................................................................
 p. Ekstremitas
..................................................................................................................
q. Kulit
..................................................................................................................

10. PEMERIKSAAN PERKEMBANGAN (penilaian berdasarkan format DDST/

DENVER II) bagi anak usia 0 – 6 th
a. kemandirian dan bergaul
..................................................................................................................
..................................................................................................................
b. motorik halus
..................................................................................................................
..................................................................................................................

c. kognitf dan bahasa

..................................................................................................................
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d. motorik kasar
..................................................................................................................

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Bagi anak diatas 6 th ditanyakan tumbuh kembang secara umum sbb:
1. berat badan saat lahir, 6 bulan, 1 tahun, dan saat ini
..................................................................................................................
..................................................................................................................
2. pertumbuhan gigi:
a. usia saat gigi tumbuh
..................................................................................................................
b. jumlah gigi
..................................................................................................................
c. masalah dengan pertumbuhan gigi
..................................................................................................................
3. usia saat menegakkan kepala, duduk, berjalan, kata-kata pertama
..................................................................................................................
 4. perkembangan sekolah lancar?
..................................................................................................................
5. interaksi dengan teman sebaya dan orang dewasa
..................................................................................................................
6. partisipasi dengan kegiatan organisasi
..................................................................................................................
11. INFORMASI LAIN
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B. ANALISA DATA
Nama : No. CM :
Umur : Diagnosa Medis:

No. Hari/ Data Fokus Masalah Etiologi Diagnosa

Tanggal/
Jam
1. DS:

DO:

2. DS:

DO:
C. Perumusan Diagnosa Keperawatan
..................................................................................................................
..................................................................................................................
..................................................................................................................
D. Intervensi Keperawatan
Nama : No. CM :
Umur : Dx. Medis :

No Tgl/Jam Dx. Kep Tujuan&Kriteria Intervensi Ttd

Hasil (NOC) (NIC)
1.
2.
E. Implementasi Keperawatan
Nama : No. CM :
Umur : Diagnosa Medis:

Hari/Tgl No Dx Implementasi Respon Ttd

/Jam
1 S:

O:

2 S:

O:
Hari/Tgl No Dx Implementasi Respon Ttd
/Jam
1 S:

O:

2 S:

O:
Hari/Tgl No Dx Implementasi Respon Ttd
/Jam
1 S:

O:

2 S:

O:
F. Evaluasi Keperawatan
Nama : No. CM :
Umur : Diagnosa Medis:
No Hari/Tgl/Ja Evaluasi Ttd
Dx m
1 S:

O:

A:

P:

2 S:

O:

A:

P:
No Hari/Tgl/Jam Evaluasi Ttd
Dx
1 S:

O:

A:

P:

2 S:

O:

A:

P:
No Hari/Tgl/Jam Evaluasi Ttd
Dx
1 S:

O:

A:

P:

2 S:

O:

A:

P:
II. Pembahasan (berdasarkan tinjauan teori / Evidence Based Praktice)
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III. Daftar Pustaka

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