PROGRAM STUDI PROFESI NERS

SEKOLAH TIGGI ILMU KESEHATAN FALETEHAN

ILMU KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

FORMAT PENGKAJIAN ANAK

Nam Mahasiswa :..........................................................................

Tempat Praktik : .........................................................................

Tanggal Praktik : .........................................................................

I. Identitas Data

a. Nama :.....................................................

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

c. Nama ayah/ ibu : ....................................................

d. Pekerjaan ayah :.....................................................

e. Pekerjaan ibu :.....................................................

f. Alamat :.............................................................................................

g. Suku bangsa :.....................................................

h. Pendidikan ayah :.....................................................

i. Pendidika ibu :.....................................................

II. Keluhan Utama

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Riwayat kehamilan dan kelahiran

a. Prenatal :...........................................................................................

b. Intranatal : ..........................................................................................

c. Postnatal : ..........................................................................................

III. Riwayat Masa Lampau

a. Penyakit waktu kecil : .........................................................................

b. Pernah dirawat di RS :..........................................................................

c. Obat – obatan yang di gunakan :..............................................................

d. Tindakan (operasi) : .........................................................................

e. Alergi :..........................................................................

f. Kecelakaan : .........................................................................

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g. Imunisasi : .........................................................................

IV. Riwayat Keluarga (Disertai Genogram)

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V. Riwayat Sosial

1. Yang mengasuh : .........................................................................

2. Hubungan dengan anggota keluarga : .....................................................

3. Hubungan dengan teman sebaya :............................................................

4. Pembawaan secara umum :......................................................................

5. Lingkungan rumah :..........................................................................

VI. Kebutuhan Dasar

1. Makanan yang disukai / tidak disukai :....................................................

a. Selera :..........................................................................

b. Alat makanan yang dipakai : .............................................................

c. Pola makan/ jam : .........................................................................

2. Pola tidur : .........................................................................

a. Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa

saat tidur, dll) :..........................................................................

3. Mandi :..........................................................................

4. Aktivitas bermain : .........................................................................

5. Eliminasi :..........................................................................

VII. Keadaan Kesehatan Saat Ini

1. Diagnosa medis : .........................................................................

2. Tindakan operasi : .........................................................................

3. Status nutrisi : .........................................................................

4. Status cairan : .........................................................................

5. Obat – obatan : .........................................................................

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6. Aktivitas :..........................................................................

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7. Tindakan keperawatan :..........................................................................

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8. Hasil laboratorium : .........................................................................

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9. Hasil rongten : .........................................................................

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10. Data tambahan : .........................................................................

VIII. Pemeriksaan Fisik

Keadaan umum :........................................................................................

TB/ BB (persentile) :......................................................................................

Lingkar kepala : .......................................................................................

Mata : .......................................................................................

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Hidung :........................................................................................

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Mulut : .......................................................................................

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Telinga : .......................................................................................

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Tengkuk : .......................................................................................

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Dada : .......................................................................................

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Jantung : .......................................................................................

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Paru – paru : .......................................................................................

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Perut : .......................................................................................

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Punggung : .......................................................................................

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Genitalia : .......................................................................................

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Ekstremitas : .......................................................................................

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Kulit : .......................................................................................

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Tanda vital : .......................................................................................

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IX. Pemeriksaan Tingkat Perkembangan

1. Kemandirian dan bergaul ........................................................................

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2. Motorik halus .......................................................................................

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3. Kognitif dan bahasa .................................................................................

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4. Motorik kasar .......................................................................................

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X. Informasi Lain

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XI. Ringkasan Riwayat Keperawatan

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XII. Analisa Data

NO Data klien Etiologi Masalah keperawatan

NO Data klien Etiologi Masalah keperawatan

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PROGRAM STUDI PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN FALETEHAN SERANG

KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

CATATAN PERKEMBANGAN KEPERAWATAN

Tgl Pengkajian : Nama Pasien :

Nama Mahasiswa : Umur :

Ruang Praktik : Jenis Kelamin :

Nama Dokter : No. Rekam Medik :

Tgl/ jam Diagnosa Implementasi Keperawatan Evaluasi (SOAP)

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CATATAN PERKEMBANGAN KEPERAWATAN

Tgl/ jam Diagnosa Implementasi Keperawatan Evaluasi (SOAP)

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PROGRAM STUDI PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN FALETEHAN SERANG

KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

RENCANA KEPERAWATAN

Tgl Pengkajian : Nama Pasien : alamat rumah :

Nama Mahasiswa : Umur : nama ayah/ibu :

Ruang Praktik : Jenis Kelamin : no tlpon :

Nama Dokter : No. Rekam Medik : diagnosa medis :

No Diagnosa Tujuan Kriteria Hasil (NOC) Intervensi (NIC) Aktivitas

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RENCANA KEPERAWATAN

No Diagnosa Tujuan Kriteria Hasil (NOC) Intervensi (NIC) Aktivitas

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