FORMAT ASUHAN KEPERAWATAN ANAK

ASUHAN KEPERAWATAN PADA An…………………….

DENGAN DIAGNOSA MEDIS…………………
DI RUANG………………
TANGGAL………………………………..

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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A. ANALISIS DATA
DATA MASALAH/ PROBLEM PENYEBAB/ ETIOLOGI
DS :

DO :

DS :

DO :

DS :
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DS :

DO :

B. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS MASALAH

No. Tanggal / jam Diagnosa Keperawatan Tanggal teratasi Ttd
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C. RENCANA KEPERAWATAN
No Tujuan dan Kriteria Hasil Intervensi Rasional TTD
 D. IMPLEMENTASI KEPERAWATAN
No tanggal No. Dx Implementasi Evaluasi Proses TTD
 XVI. EVALUASI
No Hari/Tanggal/ NO Evaluasi hasil Paraf
Jam Dx
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