STIKES PANRITA HUSADA

[PROGRAM STUDI NERS] BULUKUMBA

FORMAT LAPORAN PENDAHULUAN

A. PENDAHULUAN
1. Latar Belakang
2. Tujuan:
a. Tujuan Umum
b. Tujuan Khusus
B. TINJAUAN TEORI
1. Konsep Medis
a. Defenisi
b. Etiologi
c. Tanda & gejala, klasifikasi
d. Patofisiologi
e. Komplikasi
f. Pemeriksaan penunjang
g. Penatalaksanaan
2. Konsep Asuhan keperawatan
a. Pengkajian
b. Diagnosis keperawatan
c. Rencana asuhan keperawatan
d. Evaluasi
C. PENUTUP
Kesimpulan

Keterangan:
Laporan boleh diketik / tulis tangan dan dimasukkan ke dalam map file berwarna merah.

KEPERAWATAN ANAK 1
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

FORMAT PENGKAJIAN RUANG PERAWATAN ANAK

No. RM :………………………..
Tanggal :………………………..
Tempat :………………………..
I. DATA UMUM
1. Identitas Klien
Nama : ……………………… Umur :………………………
Tempat/Tanggal lahir : ……………………… Jenis kelamin : L / P /
Agama : ……………………… Suku :………………………......
Pendidikan : ……………………… Dx. Medis :…………………….
Alamat :……………………………………………………………….
Telp :. ………………...........
Tanggal masuk RS : ………………………
Ruangan :………………………
Golongan darah : ………………………
Sumber info :………………………..

2. Identitas Orangtua
Ayah
Nama : ……………………… Umur :…………………
Pendidikan : ……………………… Pekerjaan :…………………
Alamat : ………………………………………………………………
Telp. : ......................................................………
Ibu
Nama : ……………………… Umur : ………………...
Pendidikan : ……………………… Pekerjaan : …………………
Alamat : ……………………………………………………………....
Telp :………………...

Lain-lain (hubungan keluarga ………………………………………………)

Nama : ………………………
Umur : ………………………
Pendidikan : ………………………
Pekerjaan : ………………………
Alamat : ………………………………………………………………
Telp :. ………………...

3. Identitas Saudara (terutama satu rumah)

Umur
No Nama Hubungan Status kesehatan
(thn)
1.
2.
3.
4.
5.

KEPERAWATAN ANAK 2
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

II. RIWAYAT KESEHATAN SAAT INI

1. Keluhan utama : ……………………………………………………………………
2. Alasan masuk RS : ……………………………………………………………………

3. (Uraikan naratif) : ……………………………………………………………………

……………………………………………………………………

4. Riwayat Penyakit
Provocative/Palliative : ………………………………………… (Uraikan naratif)
Quality : ………………………………………… (Uraikan naratif)
Region : ………………………………………… (Uraikan naratif)
Severity : ………………………………………… (Uraikan naratif)
Timing : ………………………………………… (Uraikan naratif)

III. RIWAYAT KESEHATAN MASA LALU

(Khusus untuk anak usia 0-5 tahun)
1. Prenatal
a. Pemeriksaan kehamilan : ……….. kali
b. Keluhan selama hamil : ………………………………………………. (Uraikan naratif)
(meliputi perdarahan, infeksi, muntah, dll)
c. Riwayat terpapar radiasi : ………………………………………………. (Uraikan naratif)
d. sRiwayat terapi obat : ………………………………………………. (Uraikan naratif)
e. Kenaikan BB selama hamil: ………... kg
f. Immunisasi TT : ………... kali
g. Golongan darah ibu : ………...
h. Golongan darah ayah : ………...

2. Natal
a. Tempat melahirkan : ………………………………………………
b. Lama dan jenis persalinan : □ spontal □ forcep □ operasi
□ lain-lain …………………………..
c. Penolong persalinan : □ dokter □ bidan □ perawat □ dukun ahli
□ lain-lain …………………………..
d. Komplikasi persalinan : ………………………………………………. (Uraikan naratif)

3. Postnatal
a. Kondisi bayi : □ BB lahir …….. gram □ PB lahir ……… cm
b. Penyakit anak : □ kuning □ kebiruan □ kemerahan
□ lain-lain …………………………..
c. Problem menyusui : ………………………………………………. (Uraikan naratif)
(Untuk semua usia)
1. Penyakit yang pernah dialami
Penyebab : ………………………………………… (Uraikan naratif)
Riwayat perawatan : ………………………………………… (Uraikan naratif)
Riwayat operasi : ………………………………………… (Uraikan naratif)
Riwayat pengobatan : ………………………………………… (Uraikan naratif)

2. Kecelakaan yang pernah dialami : ………………………………………………. (Uraikan naratif)

3. Riwayat alergi : …………………… (uraikan naratif meliputi tipe, reaksi dan tindakan)

KEPERAWATAN ANAK 3
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

4. Riwayat immunisasi :
No Jenis Immunisasi Waktu Pemberian Reaksi
1. BCG
2. DPT (I, II, III)
3. Polio (I, II, III, IV)
4. Campak
5. Hepatitis B
6. Lain-lain ………………..

IV. RIWAYAT KESEHATAN KELUARGA

(Genogram, dengan mencantumkan keterangan tentang kondisi kesehatan anggota keluarga saat ini, nama penyakit
yang diderita, penyebab meninggal dan usia. Genogram sekurang-kurangnya mencakup kakek, nenek, orangtua, bibi,
paman dan saudara kandung klien, anak dan cucu jika ada. Singkatan harus diberikan keterangan)
Simbol genogram :
: Laki-laki : Cerai : diadopsi : kembar
non
: Perempuan : Berpisah identik
X : Meninggal dunia ------ : tidak kawin, : kembar identik : abortus
: Klien hidup bersama
: lahir mati
RIWAYAT TUMBUH KEMBANG ANAK
1. Pertumbuhan fisik
a. Berat badan : ………………………………………………. (Uraikan naratif)
b. Tinggi badan : ………………………………………………. (Uraikan naratif)
c. Waktu tumbuh gigi : ………. bulan Tanggalnya gigi : ……….. bulan/tahun

2. Perkembangan tiap tahap

Usia anak saat ini :
a. Berguling :
b. Duduk :
c. Merangkak :
d. Berdiri :
e. Berdiri :
f. Berjalan :
g. Berjalan :
h. Senyum pertama pada orang :
i. Bicara pertama kali :
j. Berpakaian sendiri :

V. RIWAYAT NUTRISI
1. Pemberian ASI (sejak/lamanya) : ………………………………………………. (Uraikan naratif)
2. Pemberian susu formula (sejak/alasan/lamanya/cara) : ………………………… (Uraikan naratif)
3. Pemberian makanan tambahan (sejak/jenis) : ……………………………………(Uraikan naratif)
4. Pola perubahan nutrisi :
Usia Jenis nutrisi Lama pemberian
1. 0 – 4 bulan

2. 4 – 12 bulan

3. Saat ini
(………. bln/thn)

KEPERAWATAN ANAK 4
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

VI. RIWAYAT PSIKO-SOSIO-SPIRITUAL

1. Riwayat psikososial
a. Tempat tinggal : ………………………………………… (Uraikan naratif)
b. Lingkungan rumah : ………………………………………… (Uraikan naratif)
c. Hubungan antar anggota keluarga : ………………………………………… (Uraikan naratif)
d. Pengasuh anak : ………………………………………… (Uraikan naratif)

2. Riwayat spiritual
a. Support sistem : ………………………………………… (Uraikan naratif)
b. Kegiatan keagamaan : ………………………………………… (Uraikan naratif)

3. Riwayat hospitalisai
a. Pemahaman keluarga tentang sakit dan rawat inap di rumah sakit : ………… (Uraikan naratif)
b. Pemahaman anak tentang sakit dan rawat inap : ……………………………. (Uraikan naratif)

VII. KEBUTUHAN DASAR / POLA KEBIASAAN SEHARI-HARI

1. Nutrisi
Sebelum sakit : ……………… (meliputi selera makan, menu, frekwensi, makanan keseukaan,
pantangan dan masalahnya)
Saat sakit : ……………… (meliputi selera makan, menu, frekwensi, makanan keseukaan,
pantangan dan masalahnya)
2. Cairan
Sebelum sakit : ……………… (meliputi jenis minuman, frekwensi, kebutuhan cairan, cara
pemenuhan dan masalahnya)
Saat sakit : ……………… (meliputi jenis minuman, frekwensi, kebutuhan cairan, cara
pemenuhan dan masalahnya)

3. Istirahat/Tidur
Sebelum sakit : ……………… (meliputi jam tidur siang/malam, pola tidur, kebiasan sebelum tidur
dan masalahnya)
Saat sakit : ……………… (meliputi jam tidur siang/malam, pola tidur, kebiasan sebelum tidur
dan masalahnya)

4. Eliminasi fekal/BAB
Sebelum sakit : ……………… (meliputi frekwensi, volume, konsistensi, warna, penggunaan
pencahar, bau, dan lain-lain)
saat sakit : ……………… (meliputi frekwensi, volume, konsistensi, warna, penggunaan
pencahar, bau, dan lain-lain)

5. Eliminasi urine/BAK
Sebelum sakit : ……………… (meliputi frekwensi, volume, kejernihan, warna, bau,
Penggunaan alat batu miksi dan lain-lain)
Saat sakit : ……………… (meliputi frekwensi, volume, kejernihan, warna, bau,
Penggunaan alat batu miksi dan lain-lain)

6. Aktifitas dan latihan

Sebelum MRS : ……………… (meliputi pengalaman bekerja, lama kerja, lama jam kerja,
Jadwal kerja, jarak tempat kerja dengan rumah; jenis olahraga dan
Pelaksanaannya; jenis rekreasi dan pelaksanaannya)
Setelah MRS : ……………… (meliputi aktifitas yang klien lakukan selama dirawat)

7. Personal hygiene
Sebelum sakit : ……………… (meliputi kebiasaan mandi/frekwensi, mencuci rambut, memotong
kuku, kerapian, penampilan dan hambatan dalam personal hygiene)

KEPERAWATAN ANAK 5
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

Saat sakit : ……………… (meliputi kebiasaan mandi/frekwensi, mencuci rambut, memotong

kuku, kerapian, penampilan dan hambatan dalam personal hygiene)
8. Aktifitas sehari-hari
Sebelum sakit : ……………… (meliputi kegiatan rutin sehari-hari, pengaturan jadwal, penggunaan
alat dan masalahnya)
Saat sakit : ……………… (meliputi kegiatan rutin sehari-hari, pengaturan jadwal, penggunaan
alat dan masalahnya)

VIII. PEMERIKSAAN TINGKAT PERKEMBANGAN

1. 0 – 6 tahun
Dengan menggunakan DDST :
a. Motorik kasar : ………………………………… (Uraikan naratif)
b. Motorik halus : ………………………………… (Uraikan naratif)
c. Bahasa : ………………………………… (Uraikan naratif)
d. Personal sosial : ………………………………… (Uraikan naratif)

2. 6 tahun
a. Perkembangan kognitif : ………………………………… (Uraikan naratif)
b. Perkembangan psikoseksual : ………………………………… (Uraikan naratif)
c. Perkembangan psikososial: ………………………………… (Uraikan naratif)

IX. PEMERIKSAAN FISIK

Hari …………, tanggal ………………………, jam …………
1. Keadaan umum
a. Kesadaran : ………………………………… (Uraikan naratif)
b. Penampilan dihubungan dengan usia : ………………………………… (Uraikan naratif)
c. Ekspresi wajah : ………………………………… (Uraikan naratif)
d. Kebersihan secara umum : ………………………………… (Uraikan naratif)
e. Tanda-tanda vital : ………………………………… (Uraikan naratif)

2. Head to toe
o Kulit/integumen : …………… (meliputi textur, kelembaban, lesi, perubahan warna,
krepitasi,Sensasi, mobilitas, suhu, turgor, edema, keluhan yang berhubungan dan cara mengatasinya)
o Kepala & rambut : …………… (meliputi bentuk, ukuran, posisi, warna dan bentuk
rambut,Peradangan, kebersihan, keluhan yang berhubungan dan cara mengatasinya)
o Kuku : …………… (meliputi warna bantalan kuku, konsistensi, kontur, ketebalan,
kebersihan, keluhan yang berhubungan dan cara mengatasinya)
o Mata/penglihatan : …………… (meliputi bentuk, refleks cahaya, lapangan pandang, fungsi Sclera,
konjungtiva, pupil; akomodasi,ketajaman, pemakaian alat bantu,Peradangan, keluhan yang berhubungan dan
cara mengatasinya)
o Hidung/penghiduan : …………… (meliputi bentuk dan posisi, peradangan, perdarahan,
polip/Sumbatan, reaksi alergi, pemakaian alat bantu, fungsi penghiduan, keluhan
Yang berhubungan dan cara mengatasinya)
o Telinga/pendengaran : …………… (meliputi bentuk dan posisi, peradangan, perdarahan,
cairan,Ketajaman pendengaran, pemakaian alat bantu, keluhan yang berhubungan Dan cara mengatasinya)
o Mulut dan gigi : …………… (meliputi bibir, mukosa, gusi, lidah dan fungsi pengecapan,
Peradangan, perdarahan, kebersihan, gangguan menelan, rumusan gigi dan Kelainannya, keluhan yang
berhubungan dan cara mengatasinya)
o Leher : …………… (meliputi pembengkakan kelenjar, tiroid, tekanan vena Jugularis,
kekakuan, gerakan, keluhan yang berhubungan dan cara Mengatasinya)
o Dada : …………… (meliputi pernafasan : bentuk, pola, posisi, bunyi,dan irama;
jantung : bunyi, irama, nyeri, letak/posisi, capillary refill, suara tambahan,
CVP; keluhan yang berhubungan dan cara mengatasinya)
o Abdomen : …………… (meliputi bentuk, turgor, massa, cairan; hepar; lien; ginjal, Bising
usus, keluhan yang berhubungan dan cara mengatasinya)

KEPERAWATAN ANAK 6
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

o Perineum & genitalia : …………… (meliputi kebersihan, peradangan, perdarahan,

pembengkakan,keluhan yang berhubungan dan cara mengatasinya)
o Extremitas atas & bawah : …………… (meliputi bentuk, kekakuan, rentang gerak, refleks, tonus,
keluhan yang berhubungan dan cara mengatasinya)

3. Pengkajian Data Fokus (Pengkajian Sistem)

o Sistem respiratory
o Sistem kardiovaskuler
o Sistem gastrointestinal
o Sistem Urinaria
o Sistem Reproduksi
o Sistem Muskuloskeletal
o Sistem neurologi
o Sistem endokrin
o Sistem penglihatan
o Sistem pendengaran
o Lain-lain yang berhubungan dengan data fokus
: …………… (meliputi inspeksi, palpasi, auskultasi dan perkusi)
: …………… (meliputi inspeksi, palpasi, auskultasi dan perkusi)
: …………… (meliputi inspeksi, palpasi, auskultasi dan perkusi)
: …………… (meliputi inspeksi, palpasi, auskultasi dan perkusi)
: …………… (meliputi inspeksi, palpasi, auskultasi dan perkusi)
: …………… (meliputi inspeksi, palpasi, auskultasi dan perkusi)
: …………… (meliputi inspeksi, palpasi, auskultasi dan perkusi)
: …………… (meliputi inspeksi, palpasi, auskultasi dan perkusi)
: …………… (meliputi inspeksi, palpasi, auskultasi dan perkusi)
: …………… (meliputi inspeksi, palpasi, auskultasi dan perkusi)

4. Pemeriksaan diagnostik (meliputi tanggal dan hasil pemeriksaan)

5. Penatalaksanaan Medis (uraikan sesuai dengan anjuran medis)

X. PATOFISIOLOGI KEPERAWATAN (rangkum dalam bentuk skematis)

………………., ……………………………
Yang mengkaji,

………………………………………………
NIM :

KEPERAWATAN ANAK 7
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

FORMAT RESUME KEPERAWATAN

1. PENGKAJIAN

 Keluhan utama
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 TTV
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 Sistem yang mengalami gangguan

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2. MASALAH KEPERAWATAN

 DS : ...................................................................................................................................
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3. DIAGNOSA KEPERAWATAN
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4. RENCANA KEPERAWATAN
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KEPERAWATAN ANAK 8
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

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KEPERAWATAN ANAK 9
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

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5. IMPLEMENTASI DAN PENATALAKSANAAN MEDIK

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KEPERAWATAN ANAK 10
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

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6. EVALUASI
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7. PERENCANAAN PULANG
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KEPERAWATAN ANAK 11
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

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PEDOMAN RESUME JURNAL

Ruangan : Preceptor Klinik :

Hari/Tanggal : Preceptor Institusi :
Jam :
Nama Preceptee : 1. ……………………………
2……………………………
1. Populasi
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2. Intervensi
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3. Comparation
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4. Out Come
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5. Critikal Thingking
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Preceptor Institusi Preceptor Klinik

……………………………….. …………………………………….

KEPERAWATAN ANAK 12
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

FORMAT PROPOSAL BERMAIN PADA ANAK

Nama klien :

Usia :

Diagnosa medis :

Tingkat aktivitas :

1. Tingkat perkembangan :

2. Jenis permainan :

3. Tujuan permainan :

4. Persiapan alat :

5. Peserta :

Observer :

6. Tempat / waktu :

7. Evaluasi :

KEPERAWATAN ANAK 13
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

FORMAT PENGKAJIAN BAYI BARU LAHIR

Nama : By.

Tempat Tgl. Lahir :

Umur :

Jenis kelamin :

Kondisi Umum :

TTV :

Riwayat kelahiran

- BB : .......................
- Panjang badan
- Suhu : .......................
- Lingkar Kepala : .......................
- Lingkar dada
- Masalah dalam proses kelahiran : .......................
- Lanugo
- Vernix kaseosa : .......................
- Mekonium
: .......................
- Warna tubuh
- APGAR Score menit I
Menit V
: .......................
- Usia gestasi
: ........................

Pemeriksaaan Reflek

- Reflek moro : ...........................

- Reflek menggegam
: ...........................

- Reflek menghisap : ..........................

- Reflek tonik neck : ..........................
- Tonus otot/aktivitas

KEPERAWATAN ANAK 14
 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

: ..........................

- Kekuatan menangis : ..........................

Pemeriksaan Fisik

a. Kepala
- Bentuk kepala
- Ubun-ubun : ................................
- Mata : .................................
- Telinga
: .................................
: ..................................
- Hidung

:
- Mulut
: Reflek menelan dan menghisap.....,
labioskhisis ( ), palatoskisis ( ),
sianosis ( )

b. Punggung
- Keadaan punggung
- Fleksibelitas tulang punggung : Lecet ( ),Lordosis ( ), scoliosis ( ),

kiposis ( )
c. Thorak : ................................
- Bentuk dada
- Jenis pernapasan
- Frekuensi napas

d. Abdomen : .......................
- Bentuk abdomen
: .......................
- Bising usus
: .......................

e. Ekstremitas
- Jari kaki
- Jari tangan
- Pergerakan kaki
- Pergerakan tangan
- Garis telapak kaki
- Warna ekstremitas
- Posisi ekstremitas
: .......................
: .......................
: ...........................
: ...........................
: ...........................
: ...........................

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 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

f. Alat Reproduksi /Genitalia : ...............................

- laki-laki (penurunan testis, ukuran)
: ...............................

- perempuan (labia minora, mayora, keluaran) : ...............................

g. Fungsi Eliminasi
- Fungsi miksi
- Anus :.....................................

:......................................

:Frekuensi BAK......... warna.........

:Frekuensi BAB .........

Konsistensi ...... Warna .......

Diagnosa Medis :

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 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

KOMPETENSI KEPERAWATAN DI RUANG ANAK

Jumlah
No Jenis Kegiatan Target Total Persentase
1 2 3 4 5 6

1. Melaksanakan anamneses 4

2. Pemeriksaan fisik

Antropometri :

a. Berat badan 4

b. Tinggi badan 4

c. Lingkar lengan atas 4

d. Skin fold 4

e. Lingkar kepala 4

f. Lingkar perut 4

Pemeriksaan data fokus

a. Pernafasan 2

b. Kardiovaskuler 2

c. Pencernaan 2

d. Persyarafan 2

e. Indera 2

f. Endokrine 2

g. Perkemihan 2

h. Muskuloskeletal 2

i. Reproduksi 2

j. Imun 2

Identifikasi tumbuh kembang

a. Motorik kasar

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 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

b. Motorik halus 1

c. Bahasa 1

d. Personal social 1

3. Memenuhi kebutuhan cairan,

elektrolit dan darah

a. Mengukur intake dan output 4

b. Mengobservasi tetesan infus
dan transfusi 4
c. Melaksanakan program terapi
cairan 3
d. Memasang infus dan atau
menyiapkan transfusi 2

4 Memenuhi kebutuhan nutrisi

a. Menyiapkan makanan 4
b. Membantu memberi 4
makanan anak
c. Memberi makanan melalui
2
NGT
d. Memasang NGT 2

5 Memenuhi kebutuhan O

2 2
3
a. Melakukan suction 2
b. Membersihkan hidung
c. Memberikan O2 (sungkup, 2
inkubator, nasal kanule) 2
d. Melakukan nebulezer
e. Melakukan fisioterap dada
6 Melaksanakan pemberian obat

a. Tetes mata 1
b. Tetes telinga 1
c. Tetes hidung 1
d. Oral 6
e. IM 3
3
f. IV
2
g. SC 2
h. IC 2
i. Anal 3
j. Kulit

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 STIKES PANRITA HUSADA
[PROGRAM STUDI NERS] BULUKUMBA

7 Melakukan eliminasi

a. Memasang kateter 2
b. Melepas kateter 2
c. Merawat colostomy 1

8 Melaksanakan penyuluhan 2

9 Melaksanakan program bermain 1

10 Memelihara kebersihan

a. Mandi 4
b. Cuci rambut 4
c. Potong kuku 4
d. Gosok gigi 4
e. Oral hygiene 4

11 Imunisasi 2

KEPERAWATAN ANAK 19