format asuhan keperawatan bayi dan anak

ASUHAN KEPERAWATANA. PENGKAJIAN1. Biodata Pasien

Nama : …………………………………No. Reg : …………………………………Tgl. MRS : …………………………………Usia : …………………………………Jenis Kelamin : …………………………………Bangsa/Suku : …………………………………Agama : …………………………………Alamat : …………………………………Golongan Darah : …………………………………Diagnosa Medis : …………………………………

Nama Ibu : …………………………………Usia : …………………………………Agama : …………………………………Pendidikan : …………………………………Pekerjaan : …………………………………Alamat : …………………………………

Nama Ayah : …………………………………Usia : …………………………………Agama : …………………………………Pendidikan : …………………………………Pekerjaan : …………………………………Alamat : …………………………………

2. Keluhan Utama………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

3. Riwayat Sekarang…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………4. Riwayat penyakit dahulu………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………5. Riwayat kesehatan keluarga

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

6. Riwayat Persalinan………………………………………………………………………………………………………………………………………………………………………………………………………………

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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

7. POLA FUNGSI KESEHATANa. Pola Nutrisi

Dirumah: Dirumah sakit:

b. Pola EliminasiDirumah: Dirumah sakit:

c. Pola AktivitasDirumah: Dirumah sakit:

d. Pola Higiene (Kebersihan diri)Dirumah: Dirumah sakit:

e. Pola Istirahat dan tidurDirumah: Dirumah sakit:

8. Pemeriksaan Fisika. Keadaan Umum : ………………………………………………………..

………………………………………………………..Kesadaran : ………………………………………………………..

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TTV : Tensi ……………. Nadi ………….../mnt Suhu ………….oC RR ……………../mnt

BB : …………

b. Kepala – Leher :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

c. Dada :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

d. Abdomen :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

e. Ekstremitas :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

f. Genetelia – Anus :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

g. Px Neurologis :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

9. PEMERIKSAAN DIAGNOSTIK

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10. Penatalaksanaan / Therapi Medis

B. DIAGNOSA KEPERAWATAN1. Analisa Data

Nama : ………………………….Usia : ………………………….No. Reg : ………………………….

No Kelompok Data Masalah Penyebab

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2. Diagnosa Keperawatan berdasar PrioritasNama : ………………………….Usia : ………………………….No. Reg : ………………………….

No Tgl/Jam DiagnosaTgl/Jam Teratasi

TT

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C. INTERVENSI (RENCANA TINDAKAN)Nama : ………………………….Usia : ………………………….No. Reg : ………………………….

Tgl/Jam Dx.Kep Krit. Standart Rencana Tind Rasional TT

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Tgl/Jam Dx.Kep Krit. Standart Rencana Tind Rasional TT

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Tgl/Jam Dx.Kep Krit. Standart Rencana Tind Rasional TT

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D. IMPLEMENTASI (PELAKSANAAN)Nama : ………………………….Usia : ………………………….No. Reg : ………………………….Tgl/Jam Dx.Kep Tindakan TT

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E. EVALUASI

Nama : ………………………….Usia : ………………………….No. Reg : ………………………….Tgl/Jam Dx.Kep Evaluasi TT

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Tgl/Jam Dx.Kep Evaluasi TT

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Tgl/Jam Dx.Kep Evaluasi TT

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F. CATATAN PERKEMBANGANNama : ………………………….Usia : ………………………….No. Reg : ………………………….Tgl/Jam Dx.Kep CATATAN PERKEMBANGN TT

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Tgl/Jam Dx.Kep CATATAN PERKEMBANGN TT

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Tgl/Jam Dx.Kep CATATAN PERKEMBANGN TT

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Tgl/Jam Dx.Kep CATATAN PERKEMBANGN TT

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