ASUHAN KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

Tanggal pengkajian : .....................................................................................................

Diagnosis Medis : .....................................................................................................

A. PENGKAJIAN
1. Data umum
a. Nama KK : ...........................................................………………………
b. Umur : ...........................................................………………………
c. Pendidikan KK : ...........................................................……………………….
d. Pekerjaan KK : ...........................................................………………………
e. Agama : ...........................................................………………………
f. Suku : ...........................................................………………………
g. Alamat : ...........................................................………………………
h. Komposisi keluarga :
Jenis Hub dg
No Nama Umur Pendidikan Pekerjaan
Kelamin KK

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 Genogram Keluarga

I. Keluhan utama : .....................................................................................................................

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II. Keadaan Sakit Saat Ini
Penyakit saat ini : .........................................................................................................
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III. Riwayat kesehatan masa lalu :
A. Riwayat kelahiran dan persalinan ibu :
1. Prenatal care
a. Riwayat kunjungan prenatal : .......................Kali
b. Riwayat periksa kehamilan : Dokter Bidan
Perawat lain-lain
c. Golongan darah/ Resus ibu : …………..........
Golongan darah/Resus ayah :…………...........
d. Usia Ibu saat kehamilan anak yang sakit : .......................................
e. Riwayat penyakit selama kehamilan : ...................................................
f. Obat-obat yang digunakan : ...................................................

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 2. Natal
a. Gestasi : Aterm Prematur Postmatur
b. Tipe persalinan : Pervaginam Operasi Dengan Bantuan
c. Tempat melahirkan : ..........................................................................
d. Komplikasi persalinan : .........................................................................
3. Post natal
a. Kondisi bayi saat lahir : menangis/tidak.......................................
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b. Komplikasi bayi saat lahir : …………………………………………
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B. Riwayat Penyakit sebelumnya
1. Penyakit yang pernah diderita : ……………….....Pada umur : ………
2. Pernah dirawat di rumah sakit : Ya Tidak
3. Riwayat Operasi : ……………………………………....
4. Riwayat kecelakaan : ………………………………………
5. Obat-obatan yang digunakan : ……………………………………
6. Alergi : Ya Tidak

C. Riwayat Tumbuh Kembang Anak

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 D. Imunisasi
No Jenis imunisasi Waktu pemberian Frekuensi Reaksi setelah pemberian
1 BCG
2 DPT (I,II,III)
3 Polio (I,II,III,IV)
4 Campak
5 Hepatitis

V. Riwayat sosial
1. Pengasuh anak : ...............................................................
2. Hubungan dengan anggota keluarga: ...............................................................
3. Hubungan dengan teman sebaya : ...............................................................
4. Lingkungan rumah : ..............................................................

VI. Tipe keluarga :

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VII. Kewarganegaraan/ Suku bangsa:
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VIII. Agama :
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IX. Status sosial ekonomi keluarga:
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X. Aktivitas rekreasi keluarga:
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2. Riwayat tahap perkembangan keluarga
a. Tahap perkembangan keluarga saat ini:
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b. Tahap perkembangan keluarga yang belum terpenuhi:
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3. Keadaan lingkungan
a. Karakteristik rumah:
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b. Karakteristik tetangga dan komunitas:
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c. Mobilitas keluarga:
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d. Perkumpulan keluarga dan interaksi dengan masyarakat:
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e. Sistem pendukung keluarga
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4. Struktur keluarga:
a. Pola komunikasi keluarga
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 b. Struktur kekuatan keluarga
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c. Struktur peran keluarga
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d. Nilai dan norma keluarga
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5. Fungsi keluarga
a. Fungsi afeksi
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b. Fungsi sosial
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c. Fungsi pelayanan kesehatan
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6. Stres dan koping keluarga
a. Stresor jangka pendek dan jangka panjang
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b. Kemampuan keluarga berespon terhadap stresor
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 c. Strategi koping keluarga yang digunakan
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d. Strategi adaptasi yang disfungsi
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7. Pemeriksaan fisik
Komponen Hasil Pemeriksaan Fisik Anak

Kepala

Mata

Telinga

Hidung

Mulut dan gigi

Leher & tenggorokan

Dada

Abdomen

Ekstermitas

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 Komponen Hasil Pemeriksaan Fisik Anak

Kulit

Kuku

BB/TB

TD

Nadi

Suhu

Pernapasan

8. Harapan keluarga terhadap asuhan keperawatan

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B. DIAGNOSIS KEPERAWATAN
1. ANALISIS DATA
Data Etiologi Masalah
2. DAFTAR PRIORITAS DIAGNOSIS KEPERAWATAN

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C. RENCANA KEPERAWATAN
DIAGNOSIS TUJUAN
NO. RENCANA INTERVENSI
KEPERAWATAN TUJUAN KRITERIA HASIL
D. IMPLEMENTASI & EVALUASI
Hari, Tanggal
No Implementasi Evaluasi Paraf
Waktu
 LAPORAN PASIEN RESUME

A. DATA PERSONAL
1. Nama : .....................................................................................................
2. Alamat : .....................................................................................................
3. Tempat, tanggal lahir : .....................................................................................................
4. Jenis kelamin : .....................................................................................................
5. Agama : .....................................................................................................
6. Usia : .....................................................................................................
7. Alamat : .....................................................................................................

B. DATA PASIEN SINGKAT

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C. DATA FOKUS
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D. DIAGNOSIS KEPERAWATAN
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E. INTERVENSI KEPERAWATAN
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F. IMPLEMENTASI KEPERAWATAN
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G. EVALUASI KEPERAWATAN
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....................... ........................2022
Mahasiswa,

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