BUKU PANDUAN

PRAKTEK KLINIK KEPERAWATAN ANAK

PRODI D.III KEPERAWATAN

TA. 2022/2023

DISUSUN OLEH
TIM : KEPERAWATAN ANAK

JURUSAN KEPERAWATAN
POLITEKNIK KESEHATAN KEMENKES MEDAN
TAHUN 2023

1
 IDENTITAS MAHASISWA
DIPLOMA III KEPERAWATAN

PAS PHOTO
3X4

NAMA : .....................................................................

NIM : .....................................................................

TINGKAT : .....................................................................

TANGGAL : ............................ s/d ..................................

RUMAH SAKIT : .....................................................................

JURUSAN KEPERAWATAN
POLITEKNIK KESEHATAN KEMENKES MEDAN
TAHUN 2023

2
VISI DAN MISI PROGRAM STUDI PRODI D3 KEPERAWATAN

Visi :

Menghasilkan Ahli Madya Keperawatan dengan keunggulan

Kegawatdaruratan yang siap bersaing di tingkat Nasional dan
International Tahun 2024

Misi :

1. Menyelenggarakan pembelajaran dalam suasana akademik yang

kondusif untuk menghasilkan lulusan yang berkarakter,
kompeten, mempunyai keunggulan dalam asuhan keperawatan
kegawatdaruratan.

2. Mengembangkan penelitian sebagai upaya dalam

meningkatkan mutu layanan pendidikan dan kemajuan
keperawatan.

3. Melaksanakan pengabdian kepada masyarakat berdasarkan hasil

penelitian

4. Membangun jejaring kerjasama dengan lintas program dan lintas

sektor

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 KATA PENGANTAR

Puji Syukur kami panjatkan kepada Allah SWT Tuhan Yang Maha Esa, karena Rahmat dan
Hidayah-Nya Buku Panduan Praktek Klinik Keperawatan Anak dapat diselesaikan dengan
baik.
Buku panduan dapat mempermudah Proses Pendokumentasian Asuhan Keperawatan
serta untuk meningkatkan pengetahuan mahasiswa dalam melakukan pengkajian atau
pemeriksaan fisik secara menyeluruh (head to toe). Buku panduan praktek Keperawatan
Anakini bertujuan agar mahasiswa/i Diploma III Jurusan Keperawatan Politeknik Kesehatan
Kemenkes Medan dapat lebih mudah memahami berbagai item pemeriksaan pada masing-
masing organ tubuh mencakup anatomi dan fisiologi, baik dalam keadaan normal atau dengan
berbagai kelainan kongenital. Dalam buku panduan ini, terdapat 2 format pengkajian yaitu
format pengkajian bayi baru lahir dan format pengkajian pada anak.
Penyusun mengharapkan agar buku ini dapat dipergunakan sebaik-baiknya oleh mahasiswa
dalam rangka Proses Pembelajaran Mata Kuliah Keperawatan Anak secara komprehensif.
Buku Panduan Praktek ini masih jauh dari kesempurnaan , untuk itu sangat diharapkan
masukan, saran serta kritik yang bersifat membangun untuk tahun berikutnya.

Medan, Januari 2023

Penyusun

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 DAFTAR ISI

KATA PENGANTAR
DAFTAR ISI................................................................................................... . iii
1. PENDAHULUAN ....................................................................................... iv
1.1 Deskripsi Mata Ajar ............................................................................ . 1
1.2 Sistematika Penulisan ........................................................................ . 2

2. TUJUAN DAN KOMPETENSI................................................................. 2

2.1 Tujuan.................................................................................................. . 1
2.2 Kompetensi ......................................................................................... . 2

3. PROSES BIMBINGAN............................................................................. iv
3.1 Metode ................................................................................................ 1
3.2 Tata tertib............................................................................................. 2
3.3 Tempat Praktek.................................................................................... 3

4. PROSES PELAKSANAAN PRAKTEK.................................................. iv

5. EVALUASI ............................................................................................... . iv
5.1 Laporan ............................................................................................... 1
5.2 Kinerja Klinik dan Bermain................................................................... 2
5.3 Ujian Praktik/penyuluhan..................................................................... 3
5.4 Seminar Kasus .................................................................................... 4

6. PENUTUP ................................................................................................. iv

LAMPIRAN ................................................................................................... iv

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 BAB 1
PENDAHULUAN

1.1 Deskripsi Mata Ajar

Pelaksanaan praktek klinik Keperawatan Anak pada mahasiswa/i Diploma III Jurusan
Keperawatan tingkat II Semester IV merupakan pencapaian berbagai konsep, prinsip, teori
dan model keperawatan anak dalam berbagai tatanan pelayanan kesehatan dengan
mengintegrasikan berbagai ilmu dasar keperawatan terkait lainnya seperti ilmu bedah
anak dan ilmu kesehatan anak.

Fokus masalah pada praktek Keperawatan Anakyaitu anak dengan penyakit infeksi, non
infeksi, anak dengan penyakit yang mengancam kehidupan serta anak sehat. Mata ajar
praktek Keperawatan Anak memiliki kredit sebesar 2 SKS. Untuk dapat mengikuti
praktek Keperawatan Anak, mahasiswa harus menyelesaikan seluruh mata kuliah
prasyarat pada tahap akademik.

1.2 Sistematika Penulisan

Buku panduan praktik ini terdiri dari beberapa Bab :

1. Bab pertama merupakan Bab pendahuluan

2. Bab kedua adalah penjelasan tentang tujuan dan kompetensi yang harus dicapai oleh
mahasiswa.

3 . Bab ketiga meliputi penjelasan tentang metode pembelajaran, tata tertib dan tempat
praktik.

4. Bab keempat berisi keterangan tentang proses pelaksanaan praktik.

5. Bab kelima berisi informasi tentang evaluasi pembelajaran.

6. Bab keenam sebagai penutup.

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 BAB 2
TUJUAN DAN KOMPETENSI

2.1. Tujuan
2.1.1 Tujuan Instruksional Umum
Setelah menyelesaikan praktek Keperawatan Anak, mahasiswa dapat memberikann
asuhan keperawatan pada anak dengan berbagai tingkat usia (new born, infant,
toddler, pre school, school dan adolescent), meliputi anak sehat, anak dengan
penyakit non infeksi dan infeksi serta anak dengan penyakit yang mengancam
kehidupan diberbagai tatanan pelayanan kesehatan dengan menggunakan proses
keperawatan sebagai pendekatan, dengan mengintegrasikan bermain terapeutik
sebagai intervensi serta perawatan atraumatik.

2.1.2 Tujuan Instruksional Khusus

Setelah menyelesaikan kepaniteraan klinik peminatan keperawatan anak,
mahasiswa dapat:
2.1.2.1 Melakukan pengkajian
2.1.2.2 Menentukan masalah keperawatan
2.1.2.3 Merencanakan tindakan keperawatan
2.1.2.4 Mengintegrasikan konsep bermain dalam intervensi keperawatan
2.1.2.5 Melakukan implementasi keperawatan sesuai dengan intervensi
2.1.2.6 Mengevaluasi asuhan keperawatan yang telah diberikan
2.1.2.7 Menampilkan teknik komunikasi terapeutik pada anak dan keluarga
2.1.2.8 Menerapkan konsep perawatan anak yang sedang dirawat dan keluarga
2.1.2.9 Menerapkan konsep perawatan atraumatik dalam melakukan intervensi
pada anak sesuai dengan kasusnya
2.1.2.10 Memberikan pendidikan kesehatan pada anak dan keluarga

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2.2 Kompetensi
Mahasiswa mampu :
2.2.1 Melakukan pengkajian status kesehatan anak pada semua tingkat usia
2.2.1.1 Menganamnese riwayat kesehatan saat ini : keluhan utama langsung dari
klien (jika memungkinkan) atau dari keluarga terdekat (ayah/ibu/anggota
keluarga lainnya) dan data pendukung (hasil pemeriksaan laboratorium,
foto, EKG, EEG, dll).
2.2.1.2 Mengambil riwayat kesehatan masa lalu : riwayat prenatal, intranatal,
postnatal, diet, penyakit cedera, operasi sebelumnya, alergi, medikasi dan
imunisasi.

2.2.1.3 Melakukan pemeriksaan fisik dan pengkajian perkembangan anak sehat dan
sakit.
 Pemeriksaan Fisik
a. Pertumbuhan : Berat Badan, Tinggi Badan, Lingkar Kepala, ketebalan
kulit dan lingkar lengan atas (LLA)
b. Pengukuran tanda-tanda vital : suhu, nadi, tekanan darah, pernafasan,
tingkat kecemasan
c. Penampilan umum : kulit, kelenjar limfe, kepala, leher, mata, hidung,
telinga, dada, abdomen, punggung dan ekstremitas
d. Pengkajian persyarafan
 Pengkajian perkembangan meliputi perkembangan kongnitif, bahasa,
emosi, sosial dan psikososial
2.2.1.4 Menerapkan komunikasi verbal dan non verbal
2.2.1.5 Menerapkan konsep keperawatan atraumatik dalam pengkajian
2.2.1.6 Mengkaji reaksi anak dan keluarga terhadap hospitalisasi
2.2.1.7 Menerapkan konsep bermain saat melakukan pengkajian

2.2.2 Merumuskan format diagnosis keperawatan berdasarkan data pengkajian

2.2.2.1 Merumuskan gangguan pemenuhan kebutuhan dasar (fisik, psikologis,
sosial dan spiritual) yang dikaitkan dengan alur patofisiologis/perjalanan

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 penyakit pada setiap tingkatan usia anak dengan penyakit infeksi, non
infeksi dan penyakit yang mengancam kehidupan.
2.2.2.2 Merumuskan dan menentukan prioritas (masalah) keperawatan
2.2.2.3 Menyusun kriteria evaluasi

2.3 Menyusun rencana tindakan untuk menyelesaikan masalah anak sehat, anak
dengan infeksi, non infeksi dan penyakit yang mengancam kehidupan serta masalah
pediatrik sosial dengan menggunakan pendekatan konsep tumbuh kembang.
2.3.1 Mengintegrasikan konsep keperawatan atraumatik pada intervensi keperawatan
2.3.2 Mengintegrasikan intervensi bermain sebagai bagian intervensi keperawatan
2.3.3 Mengikutsertakan anak dan keluarga pada perencanaan asuhan keperawatan
2.3.4 Menyusun rencana pembelajaran klien dan keluarga mengacu pada prinsip
bimbingan antisipasi sesuai usia/perkembangan anak termasuk perencanaan pulang

2.4 Mengimplementasikan rencana tindakan sesuai perencanaan

2.4.1 Merencanakan rencana tindakan sesuai standar keperawatan
2.4.2 Melakukan kolaborasi dengan tenaga kesehatan lain bila diperlukan
2.4.3 Melakukan pendokumentasian tindakan keperawatan

2.5 Mengevaluasi hasil tindakan keperawatan

2.5.1 Membandingkan dengan kriteria evaluasi, melakukan analisis tindakan
dan memodifikasi rencana tindakan selanjutnya

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 BAB 3
PROSES BIMBINGAN

A. Metode
Dalam pelaksanaan bimbingan praktek klinik Keperawatan Anak, metode yang
digunakan yaitu dengan cara proses bimbingan interaktif melalui pendekatan individual
terhadap mahasiswa untuk mengembangkan kemandirian dan tanggung jawab
mahasiswa. Metode bimbingan tersebut juga mendorong penggunaan berbagai macam
strategi kreatif. Strategi kreatif tersebut meliputi : pengajaran interaktif dalam pertemuan
sebelum praktik dan sesudah praktik, studi kasus, belajar mandiri, observasi, pengajaran
afektif, pendidikan kesehatan dan pemberian penugasan.

B. Pelaksanaan Kegiatan

1. Peserta
Peserta adalah mahasiswa D-III Keperawatan Tingkat II Semester IV

2. Alokasi Waktu

- Alokasi waktu untuk masing masing mahasiswa dalam praktek klinik keperawatan anak
selama 2 minggu

- Kegiatan praktek klinik keperawatan anak d[laksanakan dalam 3 gelombang, yaitu :

1. Gelombang I tanggal 23 Januari – 4 Pebruari 2023 = 38 orang
2. Gelombang II tanggal 6 Pebruari – 18 Pebruari 2023 = 41 orang
3. Gelombang III tanggal 20 Pebruari – 4 Maret 2023 = 40 orang

- Seminar kelompok :
1. Gelombang I tanggal : 09 Pebruari 2023
2. Gelombang II tanggal : 22 Pebruari 2023
3. Gelombang III tanggal : 10 Maret 2023

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3. Tempat Pelaksanaan

Rumah Sakit Umum Dr Pirngadi Medan

Mahasiswa dibagi dalam kelompok dan dirotasikan sesuai ruang rawat yang
yang di gunakan yaitu :

- Ruang Perinatologi
- Ruang ICU Anak
- Ruang Bedah Anak
- Ruang Anak Sakit
- Ruang Anak Sehat
- Poliklinik Anak

4. Tata Tertib
- Mematuhi protokol kesehatan sesuai peraturan RSU Dr Pirngadi Medan
- Mematuhi jadwal dinas sesuai peraturan
jadwal dinas mulai dari :
Dinas Pagi : pukul 08.00 – 14.00 WIB
Dinas Sore : pukul 14.00 – 20.00 WIB
Dinas Malam : pukul 20.00 – 08.00 WIB
- Mahasiswa harus hadir 15 menit sebelum shift dimulai
- Mahasiswa yang melakukan pelanggaran terhadap seragam atau atribut sesuai
dengan peraturan yang ditetapkan, maka dianggap tidak hadir.
- Pre Conference dilakukan setiap hari pertama dinas di setiap ruang yang
dirotasikan (laporan pendahuluan harus sudah selesai dikerjakan mahasiswa)

- Follow up dilakukan 1-2 hari setelah pre conference (pengkajian dan intervensi)
- Evaluasi dilakukan setiap hari terakhir dinas di setiap ruangan yang dirotasikan
- Pengumpulan laporan dilakukan 1 hari setelah berakhir dinas di setiap ruangan
- Kegiatan therapeutik playing pada anak dapat dilakukan setelah proposal kegiatan
mendapat persetujuan dari pembimbing institusi dan clinical instruktur di lahan
praktik.

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 - Mahasiswa membawa perlengkapan praktik (Nursing Kit): thermometer, metline,
pen light/senter kecil dan stetoskop dan tensi meter)
- Kehadiran harus 100% dan mengisi daftar hadir yang di sediakan
- Apabila tidak hadir dinas maka wajib menggantinya sesuai aturan yang berlaku

- Pakaian Seragam lengkap

C. Pengorganisasian

Penanggung Jawab : Ketua Jurusan Keperawatan

Johani Dewita Nasution, SKM, Mkes
Koordinator : Dr Siang Br Tarigan, SPd, Skep, Mkes
Perceptor dari Institusi :
1. Dr Siang Br Tarigan, SPd, Skep, Mkes
2. Dina Indarsita, SST.M.Kes
3. Agustina Boru Gultom, S.Kep.M.Kes
4. Masnila Siregar,S.Kep,Ns,M.Pd
5. Nurlama Siregar,S.Kep,Ns,M.Kes
6. Nani Zulfikar,S.Kep,Ns,M.Kes
7. Dr. Risma D. Manurung,S.Kep,Ns,M.Biomed
8. Wiwik Dwi Arianti,S.Kep,Ns,M.Kep
9. Tiurlan Doloksaribu, S.Kep,Ns,M.Kep
10. Juliandi, S.Kep,NS,M.Kep
11. Ida Suryani Hasibuan, S.Kep,Ns,M.Kep
12. Sulastri GP Tambunan,S.Kep,Ns,M.Kep
13. Elvina,S.Kep,Ns.M.Kep
14. Yufdel, S.Kep,Ns,M.Kes
15. Tina, SKM,M.Kes

Tugas Perseptor :
a. Perceptor memberikan bimbingan kepada mahasiswa
b. Perceptor wajib mengisi dan menandatangani presensi kegiatan belajar mengajar profesi
setiap kali bimbingan di logbook mahasiswa
c. Memantau keaktifan, sikap etik dan moral mahasiswa serta mendiskusikan dengan
perawat ruangan hasil pemantauan tersebut
d. Mengevaluasi dan menilai laporan pendahuluan serta laporan kasus yang dibuat
mahasiswa
e. Memandu pre dan post conference di awal dan di akhir minggu. Memberikan bimbingan
dalam bentuk Bed Side Teaching (BST) kepada mahasiswa
f. Memberikan tutorial dan diskusi kasus
g. Mengikuti dan menilai presentasi kasus mahasiswa dengan analisis jurnal yang diambil
di ruangan sesuai dengan tanggungjawabnya.
h. Menilai ujian akhir stase secara komprehensif dalam hal ketrampilan maupun responsi,
serta laporan asuhan keperawatan anak.
i. Mengevaluasi Directly Observed Procedural Skill (DOPS)
j. Memberikan penilaian sikap mahasiswa
k. Menegur mahasiswa yang berperilaku diluar ketentuan yang berlaku dan menuliskan

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 dalam buku evaluasi mahasiswa

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 BAB 4
PROSES PELAKSANAAN PRAKTIK KLINIK

Pelaksanaan Praktek Klinik Keperawatan Anakmeliputi fase pra interaksi, fase introduksi,
fase kerja dan fase evaluasi yang akan diuraikan dibawah ini :

WAKTU KEGIATAN KEGIATAN BIMBINGAN

MAHASISWA
FASE PRA INTERAKSI - Mendengarkan penjelasan - Mengajukan informasi umum
Saat orientasi mahasiswa tentang informasi umum mata ajar Keperawatan Anak,
memperoleh gambaran Keperawatan Anak contoh kasus yang akan
tentang program mata - Mendengarkan tentang ditemui dilahan praktik,
ajaran Keperawatan Anak, contoh kasus karakteristik masing-masing
peraturan mata ajar, - Mendengarkan penjelasan lahan praktik, cara penulisan
besarnya SKS, metode tentang contoh-contoh laporan pendahuluan dan
pembelajaran, dan sistem kasus yang akan ditemui laporan akhir praktik klinik
evaluasi. Pada hari yang dilahan praktik, cara disetiap lahan
sama diberikan penjelasan penulisan laporan - Mengevaluasi kesiapan fisik,
tentang kasus-kasus yang pendahuluan dan laporan sosial dan mental mahasiswa
berhubungan dengan akhir praktik klinik pada - Mengevaluasi pemahaman
semua tujuan setiap lahan praktik mahasiswa tentang gambaran
pembelajaran sesuai - Mengajukan pertanyaan umum kasus-kasus yang akan
karakteristik lahan praktek yang terkait informasi ditemui dilahan praktik dan
dan strategi untuk umum tentang mata ajar, strategi pencapaian tujuan
pencapaian mata ajaran dan persiapan-persiapan pembelajaran
praktek klinik tersebut. lain yang diperkirakan - Memberikan penugasan pada
berhubungan dengan mahasiswa agar membuat
pelaksanaan laporan pendahuluan untuk
didiskusikan pada saat
pertemuan sebelum praktik
FASE INTRODUKSI - Menjelaskan laporan - Mengevaluasi kesiapan fisik,
Kegiatan dalam fase ini pendahuluan yang telah sosial dan psikologis
dilakukan di tempat dipersiapkan sehari mahasiswa untuk berinteraksi
praktik yang didahului sebelum praktik klinik dengan klien
dengan kegiatan - Menjelaskan pendekatan - Membimbing dan membantu
pertemuan sebelum praktik dan teknik komunikasi mahasiswa untuk berinteraksi
Pencapaian dari fase ini yang tepat untuk membina dengan klien
berhubungan dengan mata hubungan dengan anak - Mengevaluasi pemahaman
ajar yaitu : sesuai dengan tahap mahasiswa tentang materi
- Melakukan pengkajian perkembangan anak yang didiskusikan
status kesehatan anak - Memulai berinteraksi - Mengobservasi dan memberi
pada semua tingkat usia dengan klien dan membuat umpan balik
- Merumuskan formulasi kontrak asuhan - Memberikan penghargaan
diagnosis keperawatan keperawatan terhadap aktivitas positif
berdasarkan data mahasiswa dan peringatan
pengkajian terhadap kondisi yang akan
- Menyusun rencana membahayakan diri sendiri

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 tindakan untuk dan orang lain
menyelesaikan masalah
klien sehat, anak dengan
infeksi dan non infeksi,
serta anak dengan
penyakit yang
mengancam kehidupan
menggunakan
pendekatan konsep
tumbuh kembang
FASE KERJA - Melakukan pengkajian - Membimbing dan membantu
Pencapaian pada fase ini berdasarkan laporan mahasiswa untuk berinteraksi
terkait dengan kompetensi pendahuluan yang telah denganklien
dan tujuan mata ajar, dibuat - Memberikan umpan balik
yaitu: - Membuat perencanaan terstruktur terhadap aktivitas
- Melakukan pengkajian asuhan klien sesuai dengan mahasiswa
status kesehatan pada kasus yang telah disetujui - Mendemonstrasikan
anak pembimbing keputusan klinik yang kuat
- Merumuskan formulasi - Melakukan intervensi berkaitan dengan asuhan
diagnosis keperawatan keperawatan klien
berdasarkan data - Memberikan - Mengambil tindakan untuk
pengkajian pendidikan kesehatan memastikan keamanan pasien
- Menyusun rencana (penyuluhan) dan orang lain
tindakan untuk - Membuat rencana asuhan - Membantu dan menjaga
menyelesaikan masalah keperawatan hubungan pembelajaran
anak sehat, anak dengan - Memberikan asuhan yang antara pembimbing klinik
penyakit infeksi dan non telah direncanakan dan mahasiswa
infeksi serta anak dengan - Melakukan evaluasi - Mengorganisisr dan
penyakit yang tentang pencapaian asuhan merencanakan pengalaman
mengancam kehidupan keperawatan bersama mahasiswa dan klien
dengan mengadakan - Memberikan pertanyaan dan
pendekatan konsep komentar kepada mahasiswa
tumbuh kembang
- Mengimplementasikan
rencana tindakan sesuai
perencanaan
- Mengevaluasi hasil
tindakan keperawatan
FASE TERMINASI - Mengevaluasi tindakan - Membimbing dan
Pada saat praktik klinik keperawatan yang telah mengobservasi kinerja
pencapaian pada fase ini dilakukan mahasiswa
terkait dengan - Mengakhiri kontrak - Memberikan umpan balik
kompetensi/tujuan mata asuhan keperawatan pada terstruktur
ajar yaitu: klien - Memberikan pertanyaan dan
- Mengevaluasi hasil komentar kepada mahasiswa
tindakan keperawatan pada pertemuan setelah
praktik
FASE EVALUASI - Membuat laporan asuhan - Mengevaluasi dan

15
Satu hari setelah praktik. keperawatan memberikan umpan balik
Pencapaian pada fase ini - Melengkapi laporan ke terstruktur
terkait dengan kompetensi pembimbing - Memberi nilai terhadap
dan tujuan mata ajar yaitu: laporan mahasiswa dan
- Melakukan pengkajian menyerahkan ke koordinator
pada semua tingkat mata ajar pada akhir praktik
usia klinik.
- Merumuskan
formulasi diagnosis
keperawatan
berdasarkan data
pengkajian
- Menyusun rencana
tindakan pada anak sehat,
menyelesaikan masalah
anak dengan penyakit
infeksi dan non infeksi
serta anak dengan
penyakit yang
mengancam kehidupan
dengan mengadakan
pendekatan konsep
tumbuh kembang
- Mengimplementasikan
rencana tindakan
sesuai perencanaan
- Mengevaluasi hasil
tindakan keperawatan

16
 BAB 5
EVALUASI

Penilaian Praktek Klinik Keperawatan Anak meliputi :

- Laporan : 40%
- Ujian Praktik/Penyuluhan : 30%
- Seminar : 20%
- Target Keterampilan Klinik : 10%

5.1 Laporan
Mahasiswa menulis seluruh asuhan keperawatan yang dilakukan dengan acuan format-
format yang telah disediakan. Mahasiswa wajib mengelola tiga pasien kasus kelolaan dan
satu pasien resume selama menjalani praktek Keperawatan Anak. Mahasiswa wajib
melakukan asuhan keperawatan pada masing-masing klien kelolaan minimal 3 (tiga)
hari. Penilaian laporan mempunyai bobot penilaian tersendiri berdasarkan format
penilaian yang telah ditentukan.

Sistematika penulisan laporan terdiri dari :

Bab 1 : Laporan Pendahuluan
- Defenisi
- Etiologi
- Manifestasi klinis
- Patofisiologi
- Pemeriksaan Penunjang : Laboratorium, Foto rontgen, Fisioterapi
- Penatalaksanaan Medis : pengobatan yang diberikan
- Asuhan Keperawatan
1. Pengkajian
2. Diagnosa Keperawatan
3. Intervensi Keperawatan/Rasional
Bab 2 : Laporan Kasus
- Pengkajian
- Analisis Data

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 - Perumusan Diagnosa Keperawatan
- Rencana Asuhan Keperawatan
- Pelaksanaan Tindakan Keperawatan
- Catatan Perkembangan
Bab 3 : Pembahasan
Bab 4 : Kesimpulan dan Saran
Daftar Pustaka

Laporan harus dikerjakan dengan tulisan tangan. Laporan ditulis pada halaman berikutnya
dari buku ini. Tulisan harus jelas. Pengumpulan laporan setelah selesai melakukan asuhan
keperawatan sesuai waktu yang telah ditetapkan oleh koordinator pembimbing dan laporan
akan dikembalikan kepada mahasiswa setelah selesai dilakukan penilaian secara keseluruhan
pada praktek Keperawatan Anak.

Mahasiswa mempunyai target untuk membuat satu permainan yang berhubungan dengan
asuhan keperawatan dan sesuai dengan tahap pertumbuhan dan perkembangan anak.
Permainan yang dibuat harus berdasarkan hasil analisis ruangan dengan terlebih dahulu
menyusun Pre Planning yang harus dikonsultasikan dengan pembimbing. Kemudian
mahasiswa melakukan kegiatan bermain diruang praktik. Program bermain ini mempunyai
bobot penilaian tersendiri berdasarkan format penilaian yang telah ditentukan

5.2 Kinerja Klinik dan Bermain

Pencapaian kompetensi praktik klinik pada mata ajar Keperawatan Anakminimal 75%
dari seluruh target. Penampilan dan sikap (attitude) mahasiswa selama praktik merupakan
aspek penting dalam pencapaian kompetensi. Mahasiswa diwajibkan untuk membuat
satuan acara penyuluhan untuk bermain dengan cara membuat program terapi aktifitas
bermain pada anak dan mempraktikkan aktifitas bermain pada anak. Setiap mahasiswa
masing-masing melaksanakan satu kegiatan kelompok bermain.

18
5.3 Ujian Praktik/Penyuluhan
Ujian praktik merupakan salah satu bentuk evaluasi terhadap pengelolaan asuhan
keperawatan pada klien. Ujian praktik dilakukan perorangan dan dilakukan sesuai dengan
tempat praktek.
Hal-hal pokok yang menjadi penilaian dalam ujian praktik adalah :
a. Kemampuan dasar klinis mahasiswa yang dilakukan sebagai salah satu bentuk asuhan
keperawatan
b. Kemampuan mahasiswa dalam menguasai kasus yang ditangani saat ujian, baik secara
teoritis dan secara faktual.
Penyuluhan kepada pasien/keluarga merupakan bentuk evaluasi dari asuhan keperawatan
kepada klien. Penyuluhan dilakukan pada saat ujian praktik berlangsung dilakukan
perorangan pada minggu terakhir dinas.

5.4 Seminar Kasus

Dalam seminar kasus keperawatan anak, mahasiswa mengambil satu kasus kelolaan
selama praktik lalu diseminarkan didepan pembimbing yang dilakukan pada minggu
terakhir dinas.
Pelaksanaan seminar
 Makalah kasus kelolaan harus dikumpul sama pembimbing setiap hari Sabtu
 Seminar

19
 KEPERAWATAN ANAK
JURUSAN KEPERAWATAN POLTEKKES KEMENKES MEDAN

NAMA MAHASISWA : ....................................................................................................

TEMPAT PRAKTEK : ............................................Ruang :............................................
HARI/TANGGAL : ............................................Minggu Ke : ...................................
DIAGNOSA MEDIS : ....................................................................................................

LAPORAN PENDAHULUAN

1. KONSEP DASAR
A. DEFENISI
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B. ETIOLOGI
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C. MANIFESTASI KLINIS
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D. PATOFISIOLOGI
Skema Patofisiologi :

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 E. PEMERIKSAAN DIAGNOSTIK
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F. PENATALAKSANAAN
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II. KONSEP KEPERAWATAN

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 DAFTAR PUSTAKA

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27
 KEPERAWATAN ANAK
JURUSAN KEPERAWATAN POLTEKKES KEMENKES MEDAN

NAMA MAHASISWA : ....................................................................................................

TEMPAT PRAKTEK : ............................................Ruang :............................................
HARI/TANGGAL : ............................................Minggu Ke : ...................................
DIAGNOSA MEDIS : ....................................................................................................

PENGKAJIAN BAYI DI RUANG PERINATOLOGI

1. IDENTITAS KLIEN DAN KELUARGA

Nama Anak : ………………………………………………...L / P…………….

Jenis Kelamin : …………………...……………………………………………….

Tempat / Tgl Lahir : ……………………...…………………………………………….

Nama Ibu : ………………………...………………………………………….

Umur Ibu : …………………………...…………………………………….…

Pekerjaan Ayah : ……………………………...……………………………….……

Nama Ayah : ………………………………...………………………….………

Pekerjaan Ayah : …………………………………...…………………….…………

Suku : ……………………………………...……………….……………

Agama : ………………………………………...………….………………

Alamat : …………………………………………...…….…………………

2. PENGKAJIAN

A. RIWAYAT KEHAMILAN IBU

Pemeriksaan Kehamilan : .......................kali oleh Bidan/Dokter……...............

Imunisasi dasar : .............................................................................

28
 Penyakit yang diderita : ...........................................................................

B. RIWAYAT KELAHIRAN BAYI

Ditolong oleh dokter obgyn bidan Dukun

Lahir di klinik bersalin rumah sakit Rumah

BB lahir : ………………..gr PB lahir.............................Cm

Gestasi.….… mgg Premature postmatur KMK

Persalinan Vacuum normal seksio Caesar

APGAR SCORE : Menit I :.....................Menit II :......................

Kelainan Bawaan : ....................................................................

Imunisasi yang didapat : ....................................................................

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C. KEDUDUKAN ANAK DALAM KELUARGA :

Anak ke ………. gemelli

D. RIWAYAT PENYAKIT DALAM KELUARGA :

DM Jantung Labioskizis abortus

Tuna wicara Malformasi Kanker hemofilia

E. KEADAAN UMUM BAYI SAAT INI : Tgl : …………../……………......../ 201…....

Warna kulit merah muda Sianosis prifer Sianosis sentral

kuning

Turgor < 1 menit 1-2 menit > 2 menit

Tonus otot lunglai Lemah Kuat

29
 BB : ………………..gr PB : ………………. cm (N = 48-52)

LK :………………..cm (N = 33-37) LD : ………………. cm (N = 30-38) LILA

: ……………….cm LP..............................Cm

Postur Frog position lunglai

F. VITAL SIGN

Pernafasan / RR

Frekuensi ………….x/menit regular Irregular

Usaha nafas retraksi Gasping Grunting

pernafasan cuping hidung

Pola nafas kusmaul bradipnea Hiperpnea

cheyne stokes stridor, biot hipoventilasi

hiperventilasi Dispnea Takipnea

biot Apnea

Suara nafas vesikuller Bronchial bronkovvesikuler

wheezing Crackles Ronchi

pleura friction rub

Nadi/Pols

Frekuensi : ………….x/menit

Irama regular Irregular

Pola bradikardi takikardia sinus aritmia

pulsus paradoksus

Kekuatan 0 1+ 2+

3+ 4+

Lokasi arteri radialis dorsalis pedis poplitea

brakialis karotis

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 Suhu/temperature

: ………….°C hipertermi hipotermi

Lokasi axilla oral temporal/dahi

rectal auricular auricular/telinga

Radiasi konduksi konveksi evaporasi

Nyeri : Wong Baker

G. KEPALA DAN LEHER

Kepala

mikrosefali Makrosefali anensefali kraniotabes

hidrocephalus Edema anasarka

Trauma lahir sefal hematoma caput suksedaneum

fraktur tulang tengkorak Perdarahan subaponeurotik

Sutura Datar sedikit cekung Cekung

Cembung melebar Moulding

Cembung melebar Moulding

Fontanel anterior Datar melebar Menonjol

Cekung sedikit menonjol saat menangis

Tertutup

Fontanel posterior Datar melebar Menonjol

Cekung sedikit menonjol saat menangis

Tertutup melebar

fontanel ke 3 antara fontanel anterior - posterior (trisomi 21)

TVJ : ...................

Ukuran occipital frontalis suboccipito bregmatika

31
 Rambut

Lebat alopecia tipis kering

hitam mudah patah berkilau kurang pigmen

Rapuh

Wajah

Simetris asimetris diam asimetris senyum/menangis

Paralisis fasialis Kanan Kiri

sindrom down Sindrom piere robin

Abrasi Kontusio

Mata

Simetris Asimetris eksoftalmos enoftalmos

lagoftalmos Hordeolum Cekung Strabismus

glaucoma congenital epiforia Tuna netra

Berkedip / reflek corneal ada tidak ada

Sclera Putih / normal kuning/icterus Kebiruan

Pupil Bulat keyhole/kolobama

putih / katarak kongenital

Reflex Miosis midriasis dilatasi maksimal

Kornea jernih kekeruhan

Sekret Kering Basah

Konjungtiva Konjungtivitis pucat/anemi merah muda

bengkak/alergi

Gerakan Nistagmus doll eyes

Palpebra Tertutup hordeolum Ptosis

Edema periorbita

Lagoftalmos Pseudo lagoftalmos

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 Jarak kantus Normal canthus melebar (sindrom down)

Hidung

Simetris Asimetris Milia epistaksis

atresia koana butterfly rush pernafasan cuping hidung

Paten perforasi septum hidung kecil (sindrom down)

Septum Utuh tidak utuh

Secret Kering / dbn mukopurulen (sifilis congenital)

Mulut

Mulut Mikrognatia Trismus halitosis

Ranula Tuna wicara Rooting reflek

Palatum Utuh Palatoskizis Bercak putih

Bibir utuh Labioskizis

Simetris Asimetris reflex hisap kuat

Warna Sianosis merah muda

Membran mukosa Lembab Kering Bercak

Reflex hisap tidak ada Lemah kuat/baik

Lidah Glosoptosis Makroglosia Mikroglosia

Tremor lidah Reflek ekstrusi

Telinga

simetris Asimetris low set ears Mikrotia

Posisi sejajar mata kartilago belum terbentuk

Bentuk Aurikel Preaurikel

Serumen Dbn OMP

Fungsi Normal Tuna rungu

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H. THORAKS/DADA

simetris Asimetris paresis diafragma hernia diafragma

Bentuk funnel chest barel chest pigeon chest

Putting susu jelas terlihat = = warna sekitar

Klavikula Utuh Fraktur

Retraksi Interkosta epigastrium subkosta

Suprasternal

Suara nafas Vesikuler wheezing Bronchial

bronkovesikuler Ronchi

Jantung mur-mur hepatomegali

Kelainan ASD VSD PDA

Paru ………………x/menit Regular Ir irregular

Palpasi Fremitus

Perkusi Sonor Hipersonor/timpani Redup / pekak

Leher

simetris Asimetris Hematoma Higromakoli

Lipatan kulit dibelakang leher

Distensi Vena Jugularis Pembesaran d > 10 mm

Pergerakan Baik Duktus tirolosus

Vertebra/tulang punggung

Simetris Asimetris pembengkakan Lubang

Lesung/bercak kecil berambut Lumbosacral hemangioma

Bentuk Lordosis Kifosis Skoliosis

Skapula Fraktur disloasi

Spina bifida Open Close

Gallant reflek Reflek moro

34
I. ABDOMEN

Simetris buncit simetris asimetris buncit asimetris

Bentuk protuberant hernia diafragma Skapoid

pot belly megacolon

Palpasi benjolan ( - / + ) hepatomegali Enterokolitis

omfalokel gastroschisis Datar & lemas

Auskultasi peristaltik…..x/i Intensitas tinggi Intensitas rendah

Tali pusat Basah Kemerahan Kering

perdarahan pembengkakan Pus / nanah

Bau tidak sedap

J. EKSTREMITAS

Ekstremitas atas / lengan

sama panjang bebas bergerak simetris Asimetris

Tonus otot Aktif Lemah Startle reflek

Telapak tangan Dapat terbuka Garis tangan 1 (trisomi 21)

sindaktili akral dingin Polidaktili

Kuku drum stik Cekung Cembung

merah muda sianosis/kebiruan Paronisia

Ekstremitas bawah

simetris Asimetris Edema foot Edema dorsum

Tonus otot Aktif lemah Lunglai

Siemenline sindaktili akral dingin Polidaktili

Pes equino varus Pes equino varus

Kuku drum stik cekung Cembung

merah muda sianosis/kebiruan akral dingin

Garis pada kaki ada Tidak ada Reflek babinski

35
K. GENITOURINARI

Bayi perempuan

labia mayora labia minora labia datar Secret vagina

Klitoris menonjol tertutup labia mayora

fistula Ambiguous genitalia

Eliminasi BAK ……jam stlh lhr …….. cc/24 jam

Warna jernih kekuningan Kuning pekat

Bayi laki-laki

orifisium uretra diujung penis espispadia hipospadia

fimosis kelamin ganda Ambiguous

Skrotum Berisi testis tidak / kosong rugae

Datar / lembut warna gelap criyptorchidismus

Warna sama dengan kulit sekitarnya

Klitoris Normal hipertropi Fistula

Eliminasi BAK ……jam stlh lhr …….. cc/24 jam

Warna jernih kekuningan Kuning pekat

L. GASTROINTESTINAL

Meconium............................jam stlh lahir atresia ani hisprung

Frekuensi …… x/hari

Konsistensi lembek cair Keras

Warna hitam kehijauan Pucat Kuning

Perineum iritasi perineum Sacral dimple Fistula

36
M. KULIT

kemerahan licin Verniks kaseosa Kulit tipis

ekzema Eritema Papula Ulkus

purpura Macula pustula Nodul

tumor vesikel bula Sisik

krusta Erosi fisura Striae

petekie ekimosis edema Albinisme

hiperpigmentasi Bercak/ruam lanugo Rash

Warna coklat Biru kemerahan merah

kuning pucat

Tekstur lembut Kasar Kering

bersisik

N. PEMENUHAN KEBUTUHAN ISTIRAHAT TIDUR

Frekwensi Tidur

Frekuensi ………..x/hari ……jam/12 jam siang...................jam/12 jam malam

O. FUNGSI NEUROLOGIK DAN REFLEKS (deskripsikan cara mengkaji dan

hasilnya) Rooting dan menghisap

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Menggenggam (palmar dan plantar)

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Tonik leher

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Moro

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Melangkah

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Babinsky

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P. NUTRISI (ASI/PASI, jumlah dan waktu pemberian)
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Q. MEDIKASI DAN TERAPI
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R. PEMERIKSAAN PENUNJANG
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40
 S.KEMAMPUAN IBU BERHUBUNGAN DENGAN PERAWATAN BBL
(Deskripsikan keluhan, pertanyaan dan pernyataan ibu berhubungan dengan
perawatan BBL)
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T. RINGKASAN RIWAYAT KEPERAWATAN
(Kesimpulan hasil pengkajian yang menunjukkan informasi khusus yang perlu
mendapatkan perhatian dalam penyusunan rencana perawatan)
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MASALAH KEPERAWATAN
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DIAGNOSA KEPERAWATAN
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44
 ANALISA DATA

NO DATA ETIOLOGI MASALAH

45
46
 INTERVENSI / RENCANA ASUHAN KEPERAWATAN

Nama Pasien/umur : ................................... Diagnosa Medik : ...................................

Nama Ibu : ................................... No. RM : ...................................
Ruangan : ................................... Hari rawat inap ke : ...................................

NO DIAGNOSA KEPERAWATAN TUJUAN / KRITERIA HASIL INTERVENSI RASIONAL

47
48
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Nama Pasien/umur : ................................... Diagnosa Medik : ...................................

Nama Ibu : ................................... No. RM : ...................................
Ruangan : ................................... Hari rawat inap ke : ...................................

NO TGL/JAM DIAGNOSA IMPLEMENTASI EVALUASI PARAF

KEPERAWATAN PEMBIMBING

49
 HARI/TGL DIAGNOSA IMPLEMENTASI EVALUASI PARAF
NO
KEPERAWATAN PEMBIMBING

50
 CATATAN PERKEMBANGAN PASIEN

Nama Pasien : ................................... Diagnosa Medik : ...................................

Nama Ibu : ................................... No. RM : ...................................
Ruangan : ................................... Hari rawat inap ke : ...................................

NO HARI/TGL DIAGNOSA IMPLEMENTASI EVALUASI PARAF

KEPERAWATAN PEMBIMBING

51
 HARI/TGL DIAGNOSA IMPLEMENTASI EVALUASI PARAF
NO
KEPERAWATAN PEMBIMBING

52
 HARI/TGL DIAGNOSA IMPLEMENTASI EVALUASI PARAF
NO
KEPERAWATAN PEMBIMBING

53
 HARI/TGL DIAGNOSA IMPLEMENTASI EVALUASI PARAF
NO
KEPERAWATAN PEMBIMBING

54
 CATATAN PERKEMBANGAN PASIEN

Nama Pasien : ................................... Diagnosa Medik : ...................................

Nama Ibu : ................................... No. RM : ...................................
Ruangan : ...................................

N HARI DIAGNOSA IMPLEMENTASI EVALUASI PARAF

O /TGL KEPERAWATAN

55
85
 KEPERAWATAN ANAK
JURUSAN KEPERAWATAN POLTEKKES KEMENKES MEDAN

NAMA MAHASISWA : ....................................................................................................

TEMPAT PRAKTEK : ............................................Ruang :............................................
HARI/TANGGAL : ............................................Minggu Ke : ...................................
DIAGNOSA MEDIS : ....................................................................................................

LAPORAN PENDAHULUAN

1. KONSEP DASAR
A. DEFENISI
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B. ETIOLOGI
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C. MANIFESTASI KLINIS
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86
D. PATOFISIOLOGI
Skema Patofisiologi :

87
 E. PEMERIKSAAN DIAGNOSTIK
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F. PENATALAKSANAAN
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II. KONSEP KEPERAWATAN

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88
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90
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92
 DAFTAR PUSTAKA

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93
 KEPERAWATAN ANAK
JURUSAN KEPERAWATAN POLTEKKES KEMENKES MEDAN

NAMA MAHASISWA : ....................................................................................................

TEMPAT PRAKTEK : ............................................Ruang :............................................
HARI/TANGGAL : ............................................Minggu Ke : ...................................
DIAGNOSA MEDIS : ....................................................................................................

PENGKAJIAN BAYI DI RUANG ANAK

1. IDENTITAS KLIEN DAN KELUARGA

Nama Anak : ………………………………………………...L / P…………….

Jenis Kelamin : …………………...……………………………………………….

Tempat / Tgl Lahir : ……………………...…………………………………………….

Nama Ibu : ………………………...………………………………………….

Umur Ibu : …………………………...…………………………………….…

Pekerjaan Ayah : ……………………………...……………………………….……

Nama Ayah : ………………………………...………………………….………

Pekerjaan Ayah : …………………………………...…………………….…………

Suku : ……………………………………...……………….……………

Agama : ………………………………………...………….………………

Alamat : …………………………………………...…….…………………

2. PENGKAJIAN

A. RIWAYAT KELAHIRAN BAYI

Ditolong oleh dokter obgyn bidan Dukun

Lahir di klinik bersalin rumah sakit Rumah

94
 BB lahir : ………………..gr PB lahir.............................Cm

Gestasi.….… mgg Premature postmatur KMK

B. KEDUDUKAN ANAK DALAM KELUARGA :

Anak ke ………. gemelli

C. RIWAYAT PENYAKIT DALAM KELUARGA :

DM Jantung Labioskizis abortus

Tuna wicara Malformasi Kanker hemofilia

D. KEADAAN UMUM BAYI SAAT INI : Tgl : …………../……………......../ 201…....

Warna kulit merah muda Sianosis prifer Sianosis sentral

kuning

Turgor < 1 menit 1-2 menit > 2 menit

Tonus otot lunglai Lemah Kuat

BB : ………………..gr PB : ………………. cm (N = 48-52)

LK :………………..cm (N = 33-37) LD : ………………. cm (N = 30-38) LILA

: ……………….cm LP..............................Cm

Postur Frog position Lunglai

E. VITAL SIGN

Pernafasan / RR

Frekuensi ………….x/menit Regular Irregular

Usaha nafas retraksi Gasping Grunting

pernafasan cuping hidung

Pola nafas kusmaul bradipnea Hiperpnea

cheyne stokes stridor, biot hipoventilasi

95
 hiperventilasi Dispnea Takipnea

biot Apnea

Suara nafas vesikuller Bronchial bronkovvesikuler

wheezing Crackles Ronchi

pleura friction rub

Nadi/Pols

Frekuensi : ………….x/menit

Irama regular Irregular

Pola bradikardi takikardia sinus aritmia

pulsus paradoksus

Kekuatan 0 1+ 2+

3+ 4+

Lokasi arteri radialis dorsalis pedis poplitea

brakialis karotis

Suhu/temperature

: ………….°C hipertermi hipotermi

Lokasi axilla oral temporal/dahi

rectal auricular auricular/telinga

Radiasi konduksi konveksi evaporasi

Nyeri : Wong Baker

F. KEPALA DAN LEHER

Kepala

mikrosefali Makrosefali anensefali kraniotabes

hidrocephalus Edema anasarka

Trauma lahir sefal hematoma caput suksedaneum

96
 fraktur tulang tengkorak Perdarahan subaponeurotik

Sutura Datar sedikit cekung Cekung

Cembung melebar Moulding

Cembung melebar Moulding

Fontanel anterior Datar melebar Menonjol

Cekung sedikit menonjol saat menangis

Tertutup

Fontanel posterior Datar melebar Menonjol

Cekung sedikit menonjol saat menangis

Tertutup melebar

fontanel ke 3 antara fontanel anterior - posterior (trisomi 21)

TVJ : ...................

Ukuran occipital frontalis suboccipito bregmatika

Rambut

Lebat alopecia tipis kering

hitam mudah patah berkilau kurang pigmen

Rapuh

Wajah

Simetris asimetris diam asimetris senyum/menangis

Paralisis fasialis Kanan Kiri

sindrom down Sindrom piere robin

Abrasi Kontusio

Mata

Simetris Asimetris eksoftalmos enoftalmos

97
 lagoftalmos Hordeolum Cekung Strabismus

glaucoma congenital epiforia Tuna netra

Berkedip / reflek corneal ada tidak ada

Sclera Putih / normal kuning/icterus Kebiruan

Pupil Bulat keyhole/kolobama

putih / katarak kongenital

Reflex Miosis midriasis dilatasi maksimal

Kornea jernih kekeruhan

Sekret Kering Basah

Konjungtiva Konjungtivitis pucat/anemi merah muda

bengkak/alergi

Gerakan Nistagmus doll eyes

Palpebra Tertutup hordeolum Ptosis

Edema periorbita

Lagoftalmos Pseudo lagoftalmos

Jarak kantus Normal canthus melebar (sindrom down)

Hidung

Simetris Asimetris Milia epistaksis

atresia koana butterfly rush pernafasan cuping hidung

Paten perforasi septum hidung kecil (sindrom down)

Septum Utuh tidak utuh

Secret Kering / dbn mukopurulen (sifilis congenital)

Mulut

Mulut Mikrognatia Trismus halitosis

Ranula Tuna wicara Rooting reflek

98
 Palatum Utuh Palatoskizis Bercak putih

Bibir utuh Labioskizis

Simetris Asimetris reflex hisap kuat

Warna Sianosis merah muda

Membran mukosa Lembab Kering Bercak

Reflex hisap tidak ada Lemah kuat/baik

Lidah Glosoptosis Makroglosia Mikroglosia

Tremor lidah Reflek ekstrusi

Telinga

simetris Asimetris low set ears Mikrotia

Posisi sejajar mata kartilago belum terbentuk

Bentuk Aurikel Preaurikel

Serumen Dbn OMP

Fungsi Normal Tuna rungu

G. THORAKS/DADA

simetris Asimetris paresis diafragma hernia diafragma

Bentuk funnel chest barel chest pigeon chest

Putting susu jelas terlihat = = warna sekitar

Klavikula Utuh Fraktur

Retraksi Interkosta epigastrium subkosta

Suprasternal

Suara nafas Vesikuler wheezing Bronchial

bronkovesikuler Ronchi

Jantung mur-mur hepatomegali

Kelainan ASD VSD PDA

Paru ………………x/menit Regular Ir irregular

99
 Palpasi Fremitus

Perkusi Sonor Hipersonor/timpani Redup / pekak

Leher

simetris Asimetris Hematoma Higromakoli

Lipatan kulit dibelakang leher

Distensi Vena Jugularis Pembesaran d > 10 mm

Pergerakan Baik Duktus tirolosus

Vertebra/tulang punggung

Simetris Asimetris pembengkakan Lubang

Lesung/bercak kecil berambut Lumbosacral hemangioma

Bentuk Lordosis Kifosis Skoliosis

Skapula Fraktur disloasi

Spina bifida Open Close

Gallant reflek Reflek moro

H. ABDOMEN

Simetris buncit simetris asimetris buncit asimetris

Bentuk protuberant hernia diafragma Skapoid

pot belly megacolon

Palpasi benjolan ( - / + ) hepatomegali Enterokolitis

omfalokel gastroschisis Datar & lemas

Auskultasi peristaltik…..x/i Intensitas tinggi Intensitas rendah

Tali pusat Basah Kemerahan Kering

perdarahan pembengkakan Pus / nanah

Bau tidak sedap

100
I. EKSTREMITAS

Ekstremitas atas / lengan

sama panjang bebas bergerak simetris Asimetris

Tonus otot Aktif Lemah Startle reflek

Telapak tangan Dapat terbuka Garis tangan 1 (trisomi 21)

sindaktili akral dingin Polidaktili

Kuku drum stik Cekung Cembung

merah muda sianosis/kebiruan Paronisia

Ekstremitas bawah

Simetris Asimetris Edema foot Edema dorsum

Tonus otot Aktif lemah Lunglai

Siemenline sindaktili akral dingin Polidaktili

Pes equino varus Pes equino varus

Kuku drum stik cekung Cembung

merah muda sianosis/kebiruan akral dingin

Garis pada kaki ada Tidak ada Reflek babinski

J. GENITOURINARI

Bayi perempuan

labia mayora labia minora labia datar Secret vagina

Klitoris menonjol tertutup labia mayora

fistula Ambiguous genitalia

Eliminasi BAK ……jam stlh lhr …….. cc/24 jam

Warna jernih kekuningan Kuning pekat

101
 Bayi laki-laki

orifisium uretra diujung penis espispadia hipospadia

fimosis kelamin ganda Ambiguous

Skrotum Berisi testis tidak / kosong rugae

Datar / lembut warna gelap criyptorchidismus

Warna sama dengan kulit sekitarnya

Klitoris Normal hipertropi Fistula

Eliminasi BAK ……jam stlh lhr …….. cc/24 jam

Warna jernih kekuningan Kuning pekat

K. GASTROINTESTINAL

Meconium............................jam stlh lahir atresia ani hisprung

Frekuensi …… x/hari

Konsistensi lembek cair Keras

Warna hitam kehijauan Pucat Kuning

Perineum iritasi perineum Sacral dimple Fistula

L. KULIT

Kemerahan licin Verniks kaseosa Kulit tipis

ekzema Eritema Papula Ulkus

purpura Macula pustula Nodul

tumor vesikel bula Sisik

krusta Erosi fisura Striae

petekie ekimosis edema Albinisme

hiperpigmentasi Bercak/ruam lanugo Rash

Warna coklat Biru kemerahan merah

kuning pucat

102
 Tekstur lembut Kasar Kering

bersisik

M. PEMENUHAN KEBUTUHAN ISTIRAHAT TIDUR

Frekwensi Tidur

Frekuensi ………..x/hari ……jam/12 jam siang...................jam/12 jam malam

N. NUTRISI (ASI/PASI, jumlah dan waktu pemberian)

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O. MEDIKASI DAN TERAPI
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103
P. PEMERIKSAAN PENUNJANG
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Q. KEMAMPUAN IBU BERHUBUNGAN DENGAN PERAWATAN BBL
(Deskripsikan keluhan, pertanyaan dan pernyataan ibu berhubungan dengan
perawatan BBL)
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104
R. RINGKASAN RIWAYAT KEPERAWATAN
(Kesimpulan hasil pengkajian yang menunjukkan informasi khusus yang perlu
mendapatkan perhatian dalam penyusunan rencana perawatan)
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MASALAH KEPERAWATAN
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106
 DIAGNOSA KEPERAWATAN
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107
 ANALISA DATA

NO DATA ETIOLOGI MASALAH

108
109
 INTERVENSI / RENCANA ASUHAN KEPERAWATAN

Nama Pasien/umur : ................................... Diagnosa Medik : ...................................

Nama Ibu : ................................... No. RM : ...................................
Ruangan : ................................... Hari rawat inap ke : ...................................

NO DIAGNOSA KEPERAWATAN TUJUAN / KRITERIA HASIL INTERVENSI RASIONAL

110
111
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Nama Pasien/umur : ................................... Diagnosa Medik : ...................................

Nama Ibu : ................................... No. RM : ...................................
Ruangan : ................................... Hari rawat inap ke : ...................................

NO TGL/JAM DIAGNOSA IMPLEMENTASI EVALUASI PARAF

KEPERAWATAN PEMBIMBING

112
 HARI/TGL DIAGNOSA IMPLEMENTASI EVALUASI PARAF
NO
KEPERAWATAN PEMBIMBING

113
 CATATAN PERKEMBANGAN PASIEN

Nama Pasien : ................................... Diagnosa Medik : ...................................

Nama Ibu : ................................... No. RM : ...................................
Ruangan : ................................... Hari rawat inap ke : ...................................

NO HARI/TGL DIAGNOSA IMPLEMENTASI EVALUASI PARAF

KEPERAWATAN PEMBIMBING

114
 HARI/TGL DIAGNOSA IMPLEMENTASI EVALUASI PARAF
NO
KEPERAWATAN PEMBIMBING

115
 HARI/TGL DIAGNOSA IMPLEMENTASI EVALUASI PARAF
NO
KEPERAWATAN PEMBIMBING

116
 HARI/TGL DIAGNOSA IMPLEMENTASI EVALUASI PARAF
NO
KEPERAWATAN PEMBIMBING

117
 CATATAN PERKEMBANGAN PASIEN

Nama Pasien : ................................... Diagnosa Medik : ...................................

Nama Ibu : ................................... No. RM : ...................................
Ruangan : ...................................

N HARI DIAGNOSA IMPLEMENTASI EVALUASI PARAF

O /TGL KEPERAWATAN

86
87
42
42
 KEPERAWATAN ANAK
JURUSAN KEPERAWATAN POLTEKKES KEMENKES MEDAN

NAMA MAHASISWA :...............................................................................................

TEMPAT PRAKTEK : ..................................................Ruang :............................................
HARI/TANGGAL : ..................................................Minggu Ke : .....................................
DIAGNOSA MEDIS : ...........................................................................................................
JUDUL KASUS : ...........................................................................................................
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PENGKAJIAN DI RUANG RAWAT ANAK

1. IDENTITAS KLIEN
Nama : ...........................................................................................................
Tempat/tgl lahir : ...........................................................................................................
Nama Ayah/Ibu : ...........................................................................................................
Pekerjaan Ayah : ...........................................................................................................
Pekerjaan Ibu : ...........................................................................................................
Suku : ...........................................................................................................
Agama : ...........................................................................................................
Pendidikan Anak : ...........................................................................................................
Alamat : ...........................................................................................................
...........................................................................................................

2. KELUHAN UTAMA
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................

43
3. RIWAYAT KEHAMILAN DAN KELAHIRAN
A. PRENATAL : ...........................................................................................................
............................................................................................................
............................................................................................................
B. NATAL : ...........................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
C. POSTNATAL : ............................................................................................................
.............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
4. RIWAYAT MASA LALU
A. PENYAKIT WAKTU KECIL
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
B. PERNAH DIRAWAT DIRUMAH SAKIT (RIWAYAT HOSPITALISASI)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
C. RIWAYAT PENGGUNAAN OBAT
........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

44
 .........................................................................................................................................
D. RIWAYAT PEMBEDAHAN (TINDAKAN OPERASI)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
........................................................................................................................................
E. ALERGI
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
F. KECELAKAAN
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

5. RIWAYAT KELUARGA
GENOGRAM :

45
6. RIWAYAT SOSIAL
A. YANG MENGASUH
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
B. HUBUNGAN DENGAN ANGGOTA KELUARGA
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
C. HUBUNGAN DENGAN TEMAN SEBAYA
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
D. PEMBAWAAN SECARA UMUM
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

46
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
E. LINGKUNGAN RUMAH
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

7. KEBUTUHAN DASAR
A. MAKANAN
Makanan yang disukai/tidak disukai :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Selera/nafsu makan :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Alat makan yang dipakai :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Pola makan dan jumlah yang dikonsumsi/jam :

47
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
B. POLA TIDUR
Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa tidur):
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Tidur siang/jam :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

C. MANDI
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
D. AKTIVITAS BERMAIN
.............................................................................................................................................
....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
E. ELIMINASI
Buang Air Besar (BAB)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

48
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Buang Air Kecil (BAK)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

8. KEADAAN KESEHATAN SAAT INI

A. DIAGNOSA MEDIS
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
B. TINDAKAN OPERASI
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
. .......................................................................................................................................
.........................................................................................................................................
C. STATUS CAIRAN/HIDRASI
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
D. STATUS NUTRISI
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

49
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
E. OBAT-OBATAN
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
........................................................................................................................................
F. AKTIVITAS
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
G. TINDAKAN KEPERAWATAN
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

50
 .........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
H. HASIL PEMERIKSAAN LABORATORIUM
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
I. FOTO RONTGEN
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
J. LAIN-LAIN
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

51
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
9. PEMERIKSAAN
FISIK
A. KEADAAN UMUM
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
B. TB/BB
.....................cm..........................kg.................................................................................
.........................................................................................................................................
Tentukan status nutrisi anak
.........................................................................................................................................
.........................................................................................................................................
C. LINGKAR KEPALA
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
D. KEPALA
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
E. MATA
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
F. LEHER
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

52
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
G. TELINGA
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
H. HIDUNG
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
I. MULUT
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
J. DADA
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
K. PARU-PARU
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
L. JANTUNG
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

53
M.ABDOMEN
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
N. PUNGGUNG
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

O. GENITALIA
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
P. EKSTREMITA
S ATAS
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
BAWAH
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Q. TANDA VITAL
RR : ...............................................X/menit (reguler/ireguler)..................................
HR : ...............................................X/menit (reguler/ireguler)..................................
TD : ......................./.............................mmHg.........................................................
TEMP : .......................° C.............................................................................................

54
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
10. EMPAT PARAMETER PERKEMBANGAN (EVALUASI MENGGUNAKAN
DENVER II)
A. KEMAMPUAN MOTORIK HALUS/FINE MOTOR ADAPTIF(Jelaskan apa yang
anda lakukan dan hasilnya)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
B. MOTORIK KASAR/GROSS MOTOR (Jelaskan apa yang anda lakukan dan hasilnya)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
C. BAHASA DAN BICARA/LANGUAGE(Jelaskan apa yang anda lakukan dan hasilnya)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

55
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
D. SOSIALISASI DAN KEMANDIRIAN (Jelaskan apa yang anda lakukan dan hasilnya)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

11. PEMERIKSAAN PENUNJANG

.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
12. RINGKASAN RIWAYAT KEPERAWATAN

56
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

MASALAH KEPERAWATAN
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
13. DIAGNOSA KEPERAWATAN
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

57
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

58
 PENGKAJIAN DI RUANG RAWAT ANAK
1. IDENTITAS KLIEN
Nama : ...........................................................................................................
Tempat/tgl lahir : ...........................................................................................................
Nama Ayah/Ibu : ...........................................................................................................
Pekerjaan Ayah : ...........................................................................................................
Pekerjaan Ibu : ...........................................................................................................
Suku :
...........................................................................................................
Agama : ...........................................................................................................
Pendidikan Anak : ...........................................................................................................
Alamat : ...........................................................................................................
...........................................................................................................

2. KELUHAN UTAMA
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................

3. RIWAYAT KEHAMILAN DAN KELAHIRAN

A. PRENATAL : ...........................................................................................................
............................................................................................................
............................................................................................................
B. NATAL : ...........................................................................................................
............................................................................................................
............................................................................................................
C. POSTNATAL : ...........................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
...................................................................................................................
.......................................................................................................
4. RIWAYAT MASA LALU

59
A. PENYAKIT WAKTU KECIL
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
B. PERNAH DIRAWAT DIRUMAH SAKIT (RIWAYAT HOSPITALISASI)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
C. RIWAYAT PENGGUNAAN OBAT
........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
D. RIWAYAT PEMBEDAHAN (TINDAKAN OPERASI)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
........................................................................................................................................
E. ALERGI
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
F. KECELAKAAN
.........................................................................................................................................

60
 .............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

5. RIWAYAT KELUARGA
GENOGRAM :

6. RIWAYAT SOSIAL
A. YANG MENGASUH
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
B. HUBUNGAN DENGAN ANGGOTA KELUARGA

61
 .........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
C. HUBUNGAN DENGAN TEMAN SEBAYA
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
D. PEMBAWAAN SECARA UMUM
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
E. LINGKUNGAN RUMAH
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

7. KEBUTUHAN DASAR
A. MAKANAN
Makanan yang disukai/tidak disukai :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

62
 .........................................................................................................................................
Selera/nafsu makan :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Alat makan yang dipakai :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Pola makan/jam :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
B. POLA TIDUR
Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa tidur):
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Tidur siang/jam :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
C. MANDI

63
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
D. AKTIVITAS BERMAIN
.............................................................................................................................................
....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
E. ELIMINASI
Buang Air Besar (BAB)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Buang Air Kecil (BAK)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

8. KEADAAN KESEHATAN SAAT INI

A. DIAGNOSA MEDIS
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
B. TINDAKAN OPERASI
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

64
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
C. STATUS CAIRAN/HIDRASI
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
D. STATUS NUTRISI
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
E. OBAT-OBATAN
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
........................................................................................................................................
F. AKTIVITAS
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
G. TINDAKAN KEPERAWATAN
.........................................................................................................................................
.........................................................................................................................................

65
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
H. HASIL PEMERIKSAAN LABORATORIUM
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.............................................................................................................................................
.....................................................................................................................................
I. FOTO RONTGEN
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

66
 .........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
J. LAIN-LAIN
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
9. PEMERIKSAAN
FISIK
A. KEADAAN UMUM
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
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B. TB/BB
.....................cm..........................kg.................................................................................
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C. LINGKAR KEPALA
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D. KEPALA
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67
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E. MATA
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F. LEHER
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G. TELINGA
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H. HIDUNG
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I. MULUT
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J. DADA
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K. PARU-PARU
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68
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L. JANTUNG
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M.ABDOMEN
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N. PUNGGUNG
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O. GENITALIA
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P. EKSTREMITA
S ATAS
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BAWAH
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69
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Q. TANDA VITAL
RR : ...............................................X/menit (reguler/ireguler)..............................
HR : ...............................................X/menit (reguler/ireguler)..............................
TD : ......................./.............................mmHg.......................................................
TEMP : .......................° C............................................................................................
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10. PEMERIKSAAN TINGKAT PERKEMBANGAN
A. KEMANDIRIAN BERGAUL
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B. MOTORIK HALUS
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C. MOTORIK KASAR
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D. KOGNITIF
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E. BAHASA
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70
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11. PEMERIKSAAN PENUNJANG

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12. RINGKASAN RIWAYAT KEPERAWATAN
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13. MASALAH KEPERAWATAN

71
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14. DIAGNOSA KEPERAWATAN
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72
 POLITEKNIK KESEHATAN KEMENKES MEDAN
JURUSAN KEPERAWATAN

DAFTAR KEGIATAN BIMBINGAN PKK ANAK

DI RSU Dr PIRNGADI MEDAN

Nama Ruangan :
Waktu Pelaksanaan :

No. Hari /tgl/Jam Materi Bimbingan T. Tangan Keterangan

Pembimbing

Mengetahui Jurusan Keperawatan

Ketua Jurusan Keperawatan Poltekkes Kemenkes Medan
Poltekkes Kemenkes Medan Koordinator Pkk Anak

Johani Dewita Nasution, SKM., M.Kes Dr Siang Br Tarigan, SPd, Skep,Mkes

NIP .196505121999032001 NIP. 197212201998032004
 PENILAIAN DI RSU Dr PIRNGADI MEDAN

NAMA :
NIM :
PENILAI :

No. Yang dinilai Nilai Keterangan

1. KEJUJURAN 1 2 3 4 Nilai :
KEDISPLINAN 4 : Sangat Baik
KETERAMPILAN 3 : Baik
TANGGUNG JAWAB 2 : Cukup
KERAJINAN 1 : Kurang

Jumlah Nilai

Medan, 2023
Koordinator PKK Anak Kepala/ CI Ruangan

Siang Br Tarigan, SPd, Skep,MKes (........................................)

Nip :197212201998032004
 FORMAT PENILAIAN PRE DAN POST CONFERENCE
PRAKTEK KLINIK KEPERAWATAN ANAK

Nama Mahasiswa :
NIM :
Ruangan :
Asuhan Keperawatan :

Nilai
No Aspek yang dinilai Bobot Ket.
(1-100)
Membuat laporan pendahuluan (latar belakang, rencana
1 30
keperawatan, strategi pelaksanaan)
2 15
Menyampaikan rencana asuhan keperawatan
3 Menyampaikan hasil asuhan keperawatan 15

4 Memberi masukan (tanggapan, pendapat, ide) terhadap asuhan atau 30

pelayanan keperawatan sesuai masalahnya

5 Memberikan respon kognitif dan afektif terhadap saran dan 10

masukan
Ju m lah 100

Medan, 2023
Dosen Pembimbing

.....................................
NIP:
 FORMAT EVALUASI ASUHAN KEPERAWATAN
PRAKTEK KLINIK KEPERAWATAN ANAK

Nama Mahasiswa :
NIM :
Ruangan :
Judul Askep :

ASPEK YANG DINILAI NILAI NILAI YANG

MAKSIMUM DIDAPAT

A. PENGKAJIAN
1. Menetapkan Data Dasar yang Lengkap 10
a. Menggunakan sumber data yang sesuai
b. Menggunakan metode pengumpulan data yang sesuai
c. Mengumpulkan data yang berorientasi pada masalah dengan
menggunakan indikator
d. Menggali persepsi klien terhadap masalah kesehatan
e. Mengkaji kemampuan klien tentang kesehatan dan
pelayanan kesehatan sesuai dengan konsep dasar atau teori.
f. Mencatat data dasar secara sistematis, ringkas dan akurat.

2. Analisa Data
a. Menganalisa hubungan antar faktor yang terkait dengan 5
pengetahuan dan kemampuan klien tentang kesehatan
b. Mengidentifikasi pola dan kesenjangan antara hasil
pengkajian dengan kemampuan yang dimiliki klien tentang
kesehatan.
B. DIAGNOSA KEPERAWATAN
a. Menentapkan diagnose keperawatan pada anak berdasarkan :
- Data yang valid/ akurat 10
- Mengolah data pendukung dengan tepat
b. Menyesuaikan diagnose keperawatan sesuai dengan data yang
didapat
c. Mencatat diagnosa keperawatan pada klien secara sistematis,
ringkas dan akurat.
C. PERENCANAAN
1. Melibatkan klien dalam membuat rencana keperawatan
2. Merumuskan tujuan dengan spesifik, dapat diukur, relevan, batas
waktu 20
3. Sasaran dan tujuan diarahkan pada pencapaian kemandirian anak
4. Mengidentifikasi intervensi keperawatan yang sesuai
5. Menetapkan kriteria dan standar evaluasi
D. PELAKSANAAN
1. Memberdayakan klien dalam melaksanakan intervensi
keperawatan
2. Menggunakan teknik yang tepat dalam melaksanakan intervensi
keperawatan
3. Menggunakan strategi pendidikan kesehatan 40
4. Mendemonstrasikan keterampilan komunikasi efektif
5. Mendiskusikan kesehatan anak dan pelayanan kesehatan klien
6. Berfungsi sebagai fasilitator dalam pelayanan kesehatan
7. Mencatat intevensi keperawatan sesuai masalah keperawatan
klien secara sistematis, ringkas dan akurat
E. EVALUASI 15
1. Melibatkan klien dalam mengevaluasi asuhan keperawatan anak
2. Mengevaluasi asuhan keperawatan dengan menggunakan kriteria
dan standar evaluasi
3. Memodifikasi prioritas sasaran, tujuan dan intervensi
keperawatan sesuai hasil evaluasi
4. Mencatat hasil evaluasi dan perbaikan secara sistematis, ringkas
dan akurat
JUMLAH 100

Medan, 2023

Dosen Pembimbing

.................................................
NIP:
 FORMAT PENILAIAN PENCAPAIAN KOMPETENSI (PPK)
PRAKTEK KLINIK KEPERAWATAN ANAK

Nama Mahasiswa :
NIM :
Tingkat/Semester :

NO KOMPONEN BOBOT NILAI

Rancangan Pendidikan Kesehatan/SAP
a. Penetapan Topik, Sasaran & Tujuan 5
b. Materi dan Daftar Pustaka 10
1
c. Penetapan Metode 5
d. Penetapan Media dan Alat Bantu 5
e. Alat & Cara Evaluasi 5
Pelaksanaan Pendidikan Kesehatan
a. Membina hubungan dengan klien 10
b. Melibatkan klien dan keluarga 5
c. Menggunakan Metode secara tepat, dan
10
sesuai dengan rancangan
2
d. Menggunakan Media dan Alat dengan
10
tepat dan sesuai dengan rancangan
e. Menguasai Materi yang diberikan 10
f. Memberikan Kesempatan pada Klien
5
untuk bertanya
Evaluasi Pendidikan Kesehatan
a. Melakukan Evaluasi Hasil sesuai dengan
10
rancangan
3
b. Menyusun Rencana Tindak Lanjut hasil
5
evaluasi
c. Mendokumentasikan hasil kegiatan 5
JUMLAH 100

Medan, 2023

Pembimbing/ Penguji

................................................
NIP:
 FORMAT PENILAIAN SEMINAR
PRAKTIK KLINIK KEPERAWATAN ANAK

Judul Makalah :
Tanggal :
Nama Kelompok :

NO ASPEK YANG DINILAI SKOR IDEAL SKOR DIDAPAT

Makalah (40)
a. Sistematika Penulisan 10
b. Kelengkapan 10
1 c. Kejelasan Seluruh Materi 10
d. Sumber yang digunakan 10

Presentasi (20)
a. Ketepatan Waktu 5
2 b. Kejelasan Penyajian dan Tulisan 5
c. Efektifitas Alat Bantu 5
d. Metode presentasi yang tepat 5
Diskusi/Tanya Jawab (40)
a. Ketepatan Menjawab 10
3 b. Kemampuan Argumentasi 10
c. Kemampuan Mengorganisasi 10
d. Penampilan Profesional 10
TOTAL 100

Medan, 2023

Penguji / Pembimbing

.....................................
NIP: