FORMAT ASUHAN KEPERAWATAN ANAK

STIKES WIRA MEDIKA PPNI BALI

Nama Mahasiswa : ....................................................……………………………..............

NIM : ………………………………………………………………..............
Tempat Praktek : ………………………………………………………………..............
Tanggal : Pengkajian :...............................................................................
Praktik :...............................................................................

I. IDENTITAS PASIEN
Nama :...................................................................................................
No Rekam Medis : ..................................................................................................
Tempat/ tanggal lahir : ..................................................................................................
Umur : ..................................................................................................
Jenis Kelamin : ..................................................................................................
Suku bangsa : ..................................................................................................
Bahasa yang dimengerti : ..................................................................................................
Agama : ..................................................................................................
Nama Ayah/ Ibu/ wali : ..................................................................................................
Pendidikan ayah/ibu/wali : ..................................................................................................
Pekerjaan ayah/ibu/wali : ..................................................................................................
Alamat/ no telp : ..................................................................................................
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Diagnosa medis : ..................................................................................................

II. KELUHAN UTAMA

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III. RIWAYAT KESEHATAN SAAT INI
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IV. RIWAYAT KESEHATAN MASA LALU

a. Pre natal
Saat hamil : Ibu merokok : (ya/ tidak)
Ibu minum minuman keras : (ya/ tidak)
b. Intra dan post natal
Intranatal
• Lama persalinan
: ....................................................................................
• Saat persalinan : prematur/ matur/ serotinus
• Komplikasi persalinan
: ....................................................................................
• Terapi yang diberikan : ....................................................................................
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• Cara melahirkan : Pervaginam normal ( )

Dengan vakum ekstraksi ( )

Operasi caesar ( )
Lainnya ......................................................................
• Tempat melahirkan : Rumah Sakit ( )
Rumah Bersalin ( )
Rumah ( )
Lainnya .......................................................................
Postnatal
• Usaha nafas : Dengan bantuan ( )
Tanpa bantuan ( )
 • Kebutuhan resusitasi : .....................................................................................
• Apgar skor
: .....................................................................................
• Bayi langsung menangis : ya/ tidak
• Tangisan bayi :kuat/lemah/ lainnya (sebutkan)...................................
• Obat-obatan yang diberikan setelah lahir............................................................
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• Trauma lahir : Ada ( ) Tidak ( )
• Narkosis : Ada ( ) Tidak ( )
• Keluarnya urin/ BAB : Ada ( ) Tidak ( )
• Respon fisiologis atau prilaku yang bermakna :..................................................
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c. Penyakit yang pernah diderita : ...................................................................................
d. Hospitalisasi : ...................................................................................
e. Operasi : ...................................................................................
f. Injuri/ kecelakaan : ...................................................................................
g. Alergi : ...................................................................................
h. Imunisasi : ...................................................................................
i. Pengobatan : ...................................................................................

V. RIWAYAT PERTUMBUHAN
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VI. TINGKAT PERKEMBANGAN (Gunakan Format DDST II dan lampirkan)

a. Sosial.
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b. Motorik halus
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c. Bahasa
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d. Motorik kasar
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VII. RIWAYAT SOSIAL
a. Pengasuh : .......................................................................
b. Pembawaan secara umum : .......................................................................
 c. Hubungan dengan anggota keluarga
: .......................................................................
d. Hubungan dengan teman sebaya : .......................................................................

VIII. RIWAYAT KELUARGA

a. Sosial ekonomi :
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b. Lingkungan rumah :
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c. Penyakit keluarga :
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Genogram

IX. POLA KESEHATAN

a. Pemeliharaan dan persepsi kesehatan
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b. Nutrisi (makanan dan cairan)
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c. Aktifitas
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d. Tidur dan istirahat
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e. Eliminasi
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f. Pola hubungan
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g. Koping
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h. Kognitif dan persepsi
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i. Konsep diri
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j. Seksual
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k. Nilai
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X. PEMERIKSAAN FISIK (inspeksi – auskultasi)
a. Keadaan umum :
Tingkat kesadaran : ................................................................................................
TD : ...........mmHg Nadi : .......... x/menit RR :...x/menit
BB : ........... kg TB : .......... cm Suhu badan : ......... o C
LLA : ........... cm LK : .......... cm LP : .......... cm
b. Kulit
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c. Kepala
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d. Mata
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e. Telinga
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f. Hidung
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g. Mulut
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h. Leher
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i. Dada
Paru-paru
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 Jantung
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j. Abdomen
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k. Genetalia
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l. Ekstrimitas
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m. Neurologi
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XI. PEMERIKSAAN DIAGNOSTIK PENUNJANG

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XII. TERAPI YANG DIPEROLEH
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XIII. INFORMASI LAIN (mencakup rangkuman kesehatan klien dari gizi, fisioterapis, dll)
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ANALISIS DATA
DATA MASALAH/ PROBLEM PENYEBAB/ ETIOLOGI
DS :

DO :
 DS :

DO :

DS :

DO :

XIV. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS MASALAH

1. ...
2. ...
3. ...

XV. RENCANA KEPERAWATAN

No Diagnosa Tujuan dan Intervensi (NIC) Rasional Nama/
Keperawatan Kriteria Hasil TTD
(NOC)
1
2

3
XVI. IMPLEMENTASI
N tanggal No. Jam Implementasi Evaluasi Nama/
o Diagnosa TTD
1
2
XVII. EVALUASI

No Hari/Tanggal/Ja NO DX Evaluasi hasil Nama/Paraf

m
1

Denpasar, ………20..
 Mahasiswa,

(…………………………)