FORMAT ASUHAN KEPERAWATAN ANAK

STIKES WIRA MEDIKA PPNI BALI

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

NIM

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

Tempat Praktek : ..............

Tanggal

: Pengkajian:...............................................................................

Praktik:...............................................................................

I. IDENTITAS PASIEN

Nama

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

No Rekam Medis

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

Tempat/ tanggal lahir: ..................................................................................................

Umur

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

Jenis Kelamin

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

Suku bangsa

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

Bahasa yang dimengerti: ..................................................................................................

Agama

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

Nama Ayah/ Ibu/ wali: ..................................................................................................

Pendidikan ayah/ibu/wali: ..................................................................................................

Pekerjaan ayah/ibu/wali: ..................................................................................................

Alamat/ no telp

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

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

Tanggal MRS

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

Diagnosa medis

: ..................................................................................................II. KELUHAN UTAMA

III. RIWAYAT KESEHATAN SAAT INI

IV. RIWAYAT KESEHATAN MASA LALU

a. Pre natal

Saat hamil: Ibu merokok

: (ya/ tidak)

Ibu minum minuman keras: (ya/ tidak)

b. Intra dan post natal

Intranatal

Lama persalinan

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

Saat persalinan

: prematur/ matur/ serotinus

Komplikasi persalinan: ....................................................................................

Terapi yang diberikan: ....................................................................................

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

Cara melahirkan

: Pervaginam normal

()

Dengan vakum ekstraksi()

Operasi caesar

()

Lainnya ......................................................................

Tempat melahirkan: Rumah Sakit

()

Rumah Bersalin

()

Rumah

()

Lainnya .......................................................................

Postnatal

Usaha nafas

: Dengan bantuan

()

Tanpa bantuan

()

Kebutuhan resusitasi: .....................................................................................

Apgar skor

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

Bayi langsung menangis: ya/ tidak

Tangisan bayi

:kuat/lemah/ lainnya (sebutkan)...................................

Obat-obatan yang diberikan setelah lahir............................................................

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

Trauma lahir

: Ada() Tidak()

Narkosis

: Ada() Tidak()

Keluarnya urin/ BAB: Ada () Tidak ()

c. Penyakit yang pernah diderita : ...................................................................................

d. Hospitalisasi

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

e. Operasi

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

f. Injuri/ kecelakaan

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

g. Alergi

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

h. Imunisasi

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

i. Pengobatan

Nama obatDosis Rute Indikasi

V. RIWAYAT PERTUMBUHAN ..

..

VI. TINGKAT PERKEMBANGAN (Gunakan Format DENVER II dan lampirkan)

a. Sosial.

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

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

b. Motorik halus

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

.....................................................................................................................................c. Bahasa .....................................................................................................................................

.....................................................................................................................................d. Motorik kasar ......................................................................................................................................

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

VII. RIWAYAT SOSIAL

a. Hubungan dengan anggota keluarga: .......................................................................

b. Hubungan dengan teman sebaya: .......................................................................

VIII. RIWAYAT KELUARGA

a. Sosial ekonomi :

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

b. Lingkungan rumah :

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

c. Penyakit keluarga :

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

d. Genogram:

IX. POLA KESEHATAN

a. Pemeliharaan dan persepsi kesehatan

b. Nutrisi (makanan dan cairan)

c. Aktifitas

d. Tidur dan istirahat

e. Eliminasi

f. Pola hubungan

g. Kognitif

h. Konsep diri

i. Seksual

j. Nilai

X. PEMERIKSAAN FISIK (inspeksi auskultasi)

a. Keadaan umum :

Tingkat kesadaran : ................................................................................................

TD : ...........mmHgNadi: .......... x/menitRR

:...x/menit

BB : ........... kg

TB: .......... cm

Suhu badan: ......... o C

LLA : ........... cm

LK: .......... cm

LP

: .......... cm

b. Kepala

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

c. Mata

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

d. Telinga

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

e. Hidung

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

f. Mulut

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

g. Leher

.....................................................................................................................................h. Dada

Paru-paru

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

Jantung

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

i. Abdomen

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

j. Genetalia

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

k. Ekstrimitas

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

l. Neurologi

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

XI. PEMERIKSAAN DIAGNOSTIK PENUNJANG

XII. TERAPI YANG DIPEROLEH

Nama obatDosis Rute Indikasi

XIII. INFORMASI LAIN (mencakup rangkuman kesehatan klien dari gizi, fisioterapis, dll)

XIV. ANALISIS DATA

SIGN & SYMPTONETIOLOGI PROBLEM/

DS :

DO :

DS :

DO :

DS :

DO :

XV. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS MASALAH NODiagnosaTanggal ditemukanTanggal teratasi

XVI. RENCANA KEPERAWATAN

NoNo Diagnosa Tujuan dan Kriteria Hasil IntervensiRasional Nama/TTD

1

2

3

XVII. CATATAN PERKEMBANGAN

No Hari/Tanggal/JamNo. DiagnosaImplementasi Respon Nama/TTD

1DS

DO

DS

DO

2DSDO

3DSDO

I. EVALUASI

NoHari/Tanggal/JamNO DiagnosaEvaluasiNama/Paraf

1S :

O :

A :

P :

2S :

O :

A :

P :

Denpasar, 20..

Mahasiswa,

()