FORMAT ASUHAN KEPERAWATAN PADA REMAJA

PROGRAM STUDI ILMU KEPERAWATAN

UNIVERSITAS ALMA ATA YOGYAKARTA

I. Identitas Remaja
1. Nama pasien :
2. Tempat lahir :
3. Tangggal lahir :
4. Jenis Kelamin :
5. Tingkat pendidikan :
6. Pekerjaan :
7. Agama :
8. Suku/Ras :
9. Alamat :

II. Pengkajian
1. Status kesehatan sekarang dan masa lalu:
a. Apakah saat ini sedang mengalami sakit?
b. Seperti apa sakit yang dirasakan?
c. Apakah jika saat ini sakit, Anda sudah ke pelayanan kesehatan untuk periksa?

2. Pola persepsi pemeliharaan kesehatan:

a. Jika Anda merasakan sakit, apa yang Anda lakukan?
b. Apakah Anda sering minum obat yang dibeli di warung?
c. Apakah anda minum jamu untuk menjaga kesehatan Anda?
 3. Pola aktivitas dan latihan:
a. Apakah Anda sering berolah raga?
b. Olah raga apa yang sering Anda lakukan?
c. Berapa kali Anda melakukan olahraga dalam 1 minggu?
d. Seberapa tinggi kesibukan Anda dalam satu hari?
e. Apa saja yang Anda lakukan dalam 1 hari?
f. Apakah Anda aktif dalam organisasi?

4. Pola nutrisi:
a. TB:
b. BB:
c. Lingkar Lengan Atas:
d. Hb:
e. Berapa kali Anda makan dalam 1 hari?
f. Bagaimana porsi makan Anda?
g. Jenis makanan apa yang sering Anda konsumsi?

5. Pola seksualitas dan reproduksi:

Untuk Remaja Putri:
a. Apakah Anda sudah menstruasi?
b. Kapan pertama kali anda menstruasi?
c. Apakah Anda sering merasakan sakit ketika akan dan saat menstruasi terjadi?
d. Apa yang Anda lakukan jika merasakan sakit ketika akan dan saat menstruasi?
e. Apakah Anda terbiasa minum jamu untuk mencegah terjadinya rasa sakit saat
menstruasi?
f. Berapa kali Anda mengganti pembalut dalam sehari?
g. Apakah Anda tahu mengapa terjadi menstruasi?
h. Apakah Anda tahu tentang organ reproduksi?
i. Bagaimana Anda menjaga organ reproduksi Anda?
 Untuk Remaja Putra:
a. Apakah Anda tahu tentang organ reproduksi?
b. Bagaimana Anda menjaga organ reproduksi Anda?

6. Pola peran dan hubungan:

a. Dengan siapa Anda bermain:
b. Teman Anda laki-laki atau perempuan?
c. Apakah Anda sudah punya pacar?
d. Berapa kali Anda bertemu dengan pacar dalam 1 minggu?
e. Apa kegiatan Anda dengan pacar?
f. Apakah Anda tinggal bersama orang tua?
g. Bagaimana hubungan Anda dengan orang tua?
h. Apakah Anda sering bercerita masalah Anda dengan orang tua?

7. Pola nilai dan keyakinan?

8. Penampilan umum?
9. Perilaku selama wawancara?
10. Pola komunikasi?
11. Kemampuan interaksi?
 FORMAT ASUHAN KEPERAWATAN
KEPERAWATAN ANAK (untuk yang berumur lebih dari 28/30 hari)
UNIVERSITAS ALMA ATA PROGRAM STUDI NERS

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

NIM : .....................................................................................................................
Tempat Praktek : .....................................................................................................................
Tanggal Pengkajian: .....................................................................................................................

I. DATA IDENTITAS PASIEN

Nama : .........................................................................................................
No rekam medik : .........................................................................................................
Tempat/tgl lahir : .........................................................................................................
Usia : ...............tahun....................bulan...............hari...............................
Nama Ayah/Ibu : .........................................................................................................
Pekerjaan Ayah : .........................................................................................................
Pekerjaan Ibu : .........................................................................................................
Pendidikan Ayah : .........................................................................................................
Pendidikan Ibu : .........................................................................................................
Agama : .........................................................................................................
Alamat : .........................................................................................................
Suku bangsa : .........................................................................................................
Diagnosa Medis : .........................................................................................................

II. RIWAYAT KESEHATAN

1). Keluhan Utama
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
2). Riwayat Kesehatan Sekarang
......................................................................................................................................
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3). Riwayat Kesehatan Dahulu

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

III. RIWAYAT KEHAMILAN DAN KELAHIRAN

1). Prenatal
Kehamilan Trimester 1 :
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
Kehamilan Trimester II :
......................................................................................................................................
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......................................................................................................................................
Kehamilan Trimester III :
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2). Intranatal
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3). Post Natal
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IV. RIWAYAT MASA LALU

1). Penyakit masa kecil
......................................................................................................................................
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......................................................................................................................................

2). Riwayat dirawat di Rumah sakit

......................................................................................................................................
......................................................................................................................................
3). Alergi
......................................................................................................................................
4). Obat-obatan yang digunakan
 ......................................................................................................................................
5). Tindakan/operasi
......................................................................................................................................
6). Imunisasi : ...................................................................................................................

V. RIWAYAT KELUARGA
a. Genogram

Keterangan :

b. Riwayat Kesehatan Keluarga

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

VI. RIWAYAT SOSIAL

a. Pengasuh : .........................................................................................................
b. Hubungan dengan Anggota Keluarga
......................................................................................................................................
......................................................................................................................................
c. Hubungan dengan Teman Sebaya
......................................................................................................................................
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d. Pembawaan Secara Umum
......................................................................................................................................
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e. Lingkungan Rumah
......................................................................................................................................
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VII. KEBUTUHAN DASAR
a. Nutrisi (makanan dan cairan)
Sebelum Sakit
......................................................................................................................................
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......................................................................................................................................
Selama Sakit
......................................................................................................................................
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b. Tidur dan Istirahat
Sebelum sakit
......................................................................................................................................
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Selama Sakit
......................................................................................................................................
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c. Personal Higiene
Sebelum Sakit
......................................................................................................................................
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Selama Sakit
......................................................................................................................................
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d. Aktivitas Bermain
Sebelum Sakit
......................................................................................................................................
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Selama Sakit
......................................................................................................................................
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e. Eliminasi
Sebelum Sakit
BAB : ...........................................................................................................................
......................................................................................................................................
BAK : ...........................................................................................................................
......................................................................................................................................
Selama Sakit
BAK : ......................................................................................................................
......................................................................................................................................
BAB : ..........................................................................................................................
 ......................................................................................................................................

VIII. PEMERIKSAAN FISIK

a. Keadaan umum : .........................................................................................................
b. Kesadaran : .........................................................................................................
c. Antropometri :
Tinggi Badan : cm Lingkar Kepala : cm
Berat Badan : Kg Lingkar Dada : cm
Lingkar Lengan Atas : cm Lingkar Perut : cm
d. Tanda-tanda vital
0
TD : / mmHg Suhu : C
Nadi : kali/menit Respirasi : kali/menit
e. Kepala :
......................................................................................................................................
f. Mata :
......................................................................................................................................
g. Hidung :
......................................................................................................................................
h. Mulut :
......................................................................................................................................
i. Telinga :
......................................................................................................................................
j. Leher :
......................................................................................................................................
k. Tengkuk :
......................................................................................................................................
l. Dada :
Jantung
Inspeksi : .....................................................................................................................
Palpasi : .....................................................................................................................
Auskultasi : ..................................................................................................................

Paru-paru
Inspeksi : .....................................................................................................................
Palpasi : .....................................................................................................................
Perkusi : .....................................................................................................................
Auskultasi : ..................................................................................................................

Abdomen
Inspeksi : .....................................................................................................................
Auskultasi : ..................................................................................................................
Perkusi : .....................................................................................................................
Palpasi : .....................................................................................................................
 m. Urogenetalia
......................................................................................................................................
......................................................................................................................................

n. Ekstremitas
Ekstremitas Atas :
......................................................................................................................................
Ekstremitas Bawah :
......................................................................................................................................
Kulit :
......................................................................................................................................

IX. ASPEK MENTAL-INTELEKTUAL

a. Intelektual Orangtua
....................................................................................................................................
b. Support System Keluarga
....................................................................................................................................
X. PEMERIKSAAN TINGKAT PERKEMBANGAN (Gunakan KPSP)
1. Kemandirian dan Bergaul
......................................................................................................................................
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2. Motorik Halus
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3. Bernalar dan Berbahasa
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4. Motorik Kasar
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XI. TERAPI MEDIS yang DIDAPAT

Terapi yang didaptkan klien saat pengkajian
tanggal .................................................................................................................................
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XII. PEMERIKSAAN DIAGNOSTIK PENUNJANG

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XIII. ANALISA DATA
No HARI/TGL DATA PROBLEM ETIOLOGI TTD
/JAM
I. PRIORITAS MASALAH
1. ................................................................................................................................................................................................
2. ................................................................................................................................................................................................
3. ................................................................................................................................................................................................
4. ................................................................................................................................................................................................
5. ................................................................................................................................................................................................
II. RENCANA KEPERAWATAN

No HARI/TGL Dx PERENCANAAN TTD

DP /JAM KEPERAWATAN Tujuan dan Kriteria Hasil Intervensi
III. IMPLEMENTASI

No. HARI/TGL JAM IMPLEMENTASI RESPON KLIEN TTD

DP
IV. EVALUASI

No. HARI/TGL JAM CATATAN PERKEMBANGAN (SOAP) TTD

DP