FORMAT LAPORAN PENDAHULUAN

KEPERAWATAN ANAK
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_________________________________________________

Disusun Oleh :

NAMA :

NIM :

KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN MALANG
JURUSAN KEPERAWATAN
 FORMAT PENGKAJIAN
ASUHAN KEPERAWATAN PADA
ANAK
__________________________________________________________

__________________________________________________________

Disusun Oleh :

NAMA : …………….........................
NIM : ………………………………..

KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN KEMENKES
MALANG
JURUSAN KEPERAWATAN
 FORMAT PENGKAJIAN

A. PENGKAJIAN

1. PENGUMPULAN DATA
Tanggal : ___________________
I. Identitas Data
Nama : Alamat :
Tanggal lahir : No. Telp :
Umur : Kultur :
Nama ayah/ibu : Agama :
Pekerjaan ayah : Pendidikan :
Pekerjaan ibu : Anak ke :

II. ALASAN KUNJUNGAN/ KELUHAN UTAMA

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

III. RIWAYAT PENYAKIT SEKARANG

______________________________________________________________________
______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

IV. Riwayat Kehamilan dan Kelahiran

a. Prenatal : ______________________________________________________
______________________________________________________
b. Intranatal : ______________________________________________________
______________________________________________________
c. Post natal : ______________________________________________________
______________________________________________________
V. Riwayat Masa Lampau
a. Penyakit-penyakit waktu kecil___________________________________________
b. Pernah dirawat di rumah sakit___________________________________________
c. Obat-obatan_________________________________________________________
d. Tindakan (misalnya : operasi)___________________________________________
e. Allergi _____________________________________________________________
f. Kecelakaan__________________________________________________________
g. Imunisasi___________________________________________________________
VI. Riwayat Keluarga
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_____________________________________________________________
VII. Riwayat Sosial
a. Yang mengasuh ___________________________________________________
b. Hubungan dengan anggota keluarga ____________________________________
c. Hubungan dengan teman sebaya ______________________________________
d. Pembawaan secara umum ____________________________________________
e. Lingkungan rumah ___________________________________________________

VIII. Kebutuhan Dasar

a. Cairan ____________________________________________________________
b. Makanan __________________________________________________________
c. Pola tidur __________________________________________________________
d. Mandi _____________________________________________________________
e. Aktivitas/bermain ____________________________________________________
f. Eliminasi___________________________________________________________

IX. Keadaan Kesehatan Saat Ini

a. Diagnosa medis _____________________________________________________
b. Tindakan operasi ____________________________________________________
c. Status nutrisi________________________________________________________
d. Status cairan________________________________________________________
e. Obat-obatan________________________________________________________
f. Aktivitas___________________________________________________________
g. Tindakan Keperawatan_______________________________________________
h. X-Ray_____________________________________________________________
i. Lain lain___________________________________________________________

X. Pemeriksaan Fisik
a. Keadaan umum_____________________________________________________
b. Tanda vital_________________________________________________________
c. Pemeriksaan kepala leher :
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
d. Pemeriksaan Integumen :
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
e. Dada dan Thorax:
_________________________________________________________________
_________________________________________________________________
 _________________________________________________________________
_________________________________________________________________
Payudara :
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Abdomen :
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
f. Genetalia
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
g. Ekstremitas
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
XI. Pemeriksaan tingkat perkembangan (KPSP)
Interpretasi Perkembangan : Normal Meragukan Penyimpangan
XII. Informasi lain

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(_____________________________)
2. ANALISA DATA
ANALISA DATA
Nama Pasien :
Umur :
No. Register :

KEMUNGKINAN
DATA MASALAH
PENYEBAB b. DI
A
G
N
O
S
A

KEPERAWATAN (BERDASAR PRIORITAS)

Ruang :
Nama Pasien :
No. Register :
DITEMUKAN
DIAGNOSA MASALAH SELESAI
NO MASALAH
KEPERAWATAN
TGL. PARAF TGL. PARAF
c. TUJUAN, KRITERIA STANDAR, INTERVENSI, RASIONAL

RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN :
NO. REG :

TANGGAL NO DX DIAGNOSA KEPERAWATAN TUJUAN KRITERIA STANDART INTERVENSI RASIONAL TT

D. PELAKSANAAN/IMPLEMENTASI

Ruang :
Nama Pasien :
Umur :
No. Register :

DIAGNOSA
TGL TINDAKAN KEPERAWATAN PARAF
KEPERAWATAN
E. EVALUASI

EVALUASI FORMATIF

Nama :
Umur :
No. Register :………….

No.Dx.Kep. Tanggal ……………… Tanggal ……………… Tanggal ………………

EVALUASI SUMATIF
Nama :
Umur :
No. Register : ………………..

Diagnosa
tgl Evaluasi Keperawatan paraf
Keperawatan