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7/25/2019 Format Pengkajian Stase Anak Untuk Mahasiswa - Copy
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Buku EvaluasiStase Keperawatan Anak
FORMAT PENGKAJIAN
KEPERAWATAN ANAK
Pengkajian Tanggal : ........................................................................................
Jam : ........................................................................................Bila RS : ........................................................................................
Tanggal MRS : ........................................................................................Jam MRS : ........................................................................................Ruang/Kelas : ........................................................................................ No. RM : ........................................................................................
A Identitas
I Pasien II Identitas Orang Tua
Nama : ……………………… ………………………
Umur : ……………………… ………………………Jenis Kelamin : ……………………… ………………………Agama : ……………………… ………………………Pendidikan : ……………………… ………………………Pekerjaan : ……………………… ………………………Alamat : ……………………… ………………………
iagnosa Medis : ……………………… ………………………
B Keluhan Utama
…………………………………………………………………………………………………
Ri!a"at Pen"a#it $e#arang
……………………………………………………………………………………………
……%%…………………………………………………………………………………………………%%
…………………………………………………………………………………………………%%
…………………………………………………………………………………………………..
& Ri!a"at Kesehatan Masa 'alu
( Prenatal
!....P....A...." #P#T.............." taksiran $ersalinan ...............
Kenaikan BB saat %amil :................................................ kg
Pemeriksaan ke%amilan :
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
&munisasi TT :
................................................................................................................
................................................................................................................
................................................................................................................
Pen'akit 'ang diderita saat %amil:
................................................................................................................
................................................................................................................
................................................................................................................
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ (
7/25/2019 Format Pengkajian Stase Anak Untuk Mahasiswa - Copy
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Buku EvaluasiStase Keperawatan Anak
)mosi i*u $ada saat %amil:
................................................................................................................
................................................................................................................
................................................................................................................
Sika$ i*u ter%ada$ ke%amilan :................................................................................................................................................................................................................................................................................................................................................
Penggunaan +*at :
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
Perokok :
................................................................................................................
................................................................................................................
Alko%ol :
................................................................................................................
................................................................................................................
................................................................................................................
) Intra Natal
Tanggal $ersalinan : .........................................................
Pukul : .........................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
* P+st Natal , )-.am /
a. AP!AR skor : ................................................................. *. BB, : .................................................................
-. PB, : .................................................................d. ,K : .................................................................e. , : .................................................................
. Keadaan *a'i : .................................................................................................................................. .................................................................
- Pen"a#it "ang 0ernah diderita
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
1 2+s0italisasi3Tinda#an O0erasi
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$
7/25/2019 Format Pengkajian Stase Anak Untuk Mahasiswa - Copy
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Buku EvaluasiStase Keperawatan Anak
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
4 O5at6+5atan "ang diguna#an
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
7 Allergi
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
8 Imunisasi dan tes la5+rat+rium
a. &munisasi : 0 1 2a
0 1 Tidak
N
+ Jenis immunisasi 3aktu $em*erian Reaksi setela% $em*erian
(. B4!
. PT 5&"&&"&&&6
7. Polio 5&"&&"&&&"&86
9. 4am$ak
. #e$atitis
*. Tes dara%/s-reening test 'ang $erna% dilakukan :.................................................................................................................
.................................................................................................................
.................................................................................................................
) Ri!a"at Keluarga
( Pen"a#it #eluarga
a. Pen'akit keturunan :
................................................................................................................ ................................................................................................................ ................................................................................................................
*. Kelainan kongenital :................................................................................................................. ................................................................................................................ ................................................................................................................
Gen+gram
F Peng#a.ian (- Ke5utuhan &asar Manusia ,9irginia 2enders+n/
(% Perna0asan
a. ,ingkar dada : *. RR : ;/mnt-. &rama % .................................................................d. Bentuk dada % .................................................................e. Pengem*angan dada % .................................................................. Batuk % .................................................................g. <rekuensi % .................................................................%. Pera=atan/$engo*atan % .................................................................i. Pola naas % .................................................................
j. Alat *antu naas % .................................................................k. Pemakaian otot *antu na$as% .................................................................
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7/25/2019 Format Pengkajian Stase Anak Untuk Mahasiswa - Copy
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Buku EvaluasiStase Keperawatan Anak
...............................................................................................................l. Sesak na$as % .................................................................
................................................................. .................................................................
m. Perna$asan % .................................................................n. Jenis % .................................................................
o. Suara naas % ................................................................. $. Perna$asan -u$ing %idung : & ' Ada
& ' Tidak
>. 8okal $remitus % .................................................................r. Sianosis % .................................................................s. Kemam$uan anak % .................................................................
)% Nutrisi dan airan
a Ri!a"at Nutrisi
( Pem*erian AS&........................................................................................................................................................................................................................
........................................................................................................................................................................................................................
............................................................................................................
............................................................................................................ Pem*erian susu ormula
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
7 Pola $eru*a%an nutrisi tia$ ta%a$ usia sam$ai nutrisi saat ini
Usia Jenis Nutrisi 'ama Pem5erian
( ? @ Bulan
@ ( Bulan7 Saat ini
5 Nutrisi $aat ini
• Nasu makan % .................................................................
• <rekuensi : ;/%ari
• Porsi makan % .................................................................
• Makanan $antangan % .................................................................
• Su$lemen/itamin % .................................................................
• Minum : --/%ari
• Jenis minuman % .................................................................
Anto$ometri
BB % .................................................................TB % .................................................................,&,A % .................................................................,ingkar $erut % .................................................................,ingkar ke$ala % .................................................................
Bising usus : ;/mnt
3arna ram*ut % .................................................................
U*unCu*un % .................................................................
• Konjungtia % .................................................................
• Sklera % .................................................................
• Mukosa % .................................................................
•
Tenggorokan % ................................................................. .................................................................
• Turgor kulit % .................................................................
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ 9
7/25/2019 Format Pengkajian Stase Anak Untuk Mahasiswa - Copy
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Buku EvaluasiStase Keperawatan Anak
Bentuk a*domen % .................................................................
• A*domen % .................................................................
................................................................. .................................................................
• Pem*esaran %e$ar % .................................................................
• Pem*esaran lien % .................................................................
• Kemam$uan anak % .................................................................
Eliminasi
(/ BAK
a6 <rekuensi : ;/%ari *6 3arna %...............................................................................................
.........................-6 Bau %...............................................................................................
.........................d6 Kekeru%an %...............................................................................................
.........................e6 Pem*esaran 8U
%........................................................................................................................
6 N'eri tekan%..........................................................................................................
..............g6 8olume : --/%ari%6 Penggunaan alat *antu % ..................................................i6 Uretra %...............................................................................................
......................... j6 Ke*ersi%an genetalia % ...................................................k6 !angguan %...............................................................................................
.........................l) Kemam$uan anak
%...................................................................................................................
)/ BAB
a/ <rekuensi : ;/%ari *6 3arna %...............................................................................................
.........................-6 Konsistensi %...............................................................................................
.........................d6 Bau %...............................................................................................
.........................e6 Kondisi anus
%..........................................................................................................
..............6 Kesulitan saat BAB" jelaskan % ............................................g6 Kemam$uan anak
%..................................................................................................................
*% M+5ilisasi
• Kesimetrisan $ostur :........................................................................................................................
• Rentang gerak :........................................................................................................................
• Penggunaan alat *antu :........................................................................................................................
• Tonus otot :........................................................................................................................
• Kekuatan otot
Kanan :........................................................................................................................
Kiri :........................................................................................................................
Kemam$uan anak :........................................................................................................................
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$
7/25/2019 Format Pengkajian Stase Anak Untuk Mahasiswa - Copy
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Buku EvaluasiStase Keperawatan Anak
-% Tidur dan Istirahat
• Pola tidur
Siang : ..............jamMalam : ..............jam
• Ke*iasaan se*elum tidur :....................................................................................................................
• Kelu%an saat tidur :........................................................................................................................
Kemam$uan anak :........................................................................................................................
1% Ber0a#aian
• !anti $akaian se%ari *era$a kali :
• Kemam$uan anak memili% $akaian:
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
.
• Kemam$uan anak memakai $akaian:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
• Kemam$uan anak mele$askan $akaian:
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
.
Kemam$uan anak:
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
.4% Mem0ertahan#an $uhu Tu5uh
a. Su%u : ?4 *. Kalau anak demam" a$a 'ang dilakukan keluarga:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
-. Ke*iasaan $enggunaan ki$as angin/A4:...............................................................................................................................................................
.
d% Kemam$uan anak :........................................................................................................................
7% Men.aga #e5ersihan
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7/25/2019 Format Pengkajian Stase Anak Untuk Mahasiswa - Copy
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Buku EvaluasiStase Keperawatan Anak
• Mandi
<rekuensi : ;/%ariKemandirian :........................................................................................................................
• 4u-i ram*ut
<rekuensi : ;/%ariKemandirian :........................................................................................................................
• !osok gigi
<rekuensi : ;/%ariKemandirian :........................................................................................................................
• !unting kuku
<rekuensi : ;/%ariKemandirian :........................................................................................................................
• Kemam$uan anak :........................................................................................................................
8% Menghindari Baha"a
a. Pengertian D*a%a'a lingkunganE menurut anak:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
*. U$a'a anak untuk mengindari *a%a'a lingkungan:
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
.-. Keadaan lingkungan ruma% 'ang *er$otensi *a%a'a:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
d. AdatCistiadat/ke$er-a'aan 'ang mem$engaru%i:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
e. U$a'a orang tua untuk men-ega% -edera:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ F
7/25/2019 Format Pengkajian Stase Anak Untuk Mahasiswa - Copy
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Buku EvaluasiStase Keperawatan Anak
. Kemam$uan
anak :.................................................................................................................................
;% Ber#+muni#asi
a. Kemam$uan anak men'atakan keinginan :...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
.5% #am*atan anak dalam *erkomunikasi:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
-. Kemam$uan komunikasi ara%:
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
.d. Artikulasi *isa dimengerti
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
e. )ks$resi sesuai :......................................................................................................................... Kemam$uan anak :........................................................................................................................
(<% Be#er.a
Kemam$uan anak melaksanakan $erinta% seder%ana :
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
• Kemam$uan anak
%........................................................................................................................
((% Bermain
a% Jenis $ermainan 'ang disukai
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
*. 3aktu *ermain%........................................................................................................................
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ G
7/25/2019 Format Pengkajian Stase Anak Untuk Mahasiswa - Copy
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Buku EvaluasiStase Keperawatan Anak
-. ,ama *ermain%.....................................................................................................................
...d. Teman *ermain
%........................................................................................................................
e. Se*utkan *e*era$a nama teman :. Pemanaatan =aktu luang keluarga :g% Ritual rekreasi *ersama keluarga :(. Kemam$uan anak
%........................................................................................................................
()% Beri5adah
Agama %...............................................................................................
......................... 3aktu i*ada%
%........................................................................................................................
Pengajaran/$enera$an -ara *eri*ada% ole% orang tua :
&nisiati *eri*ada%
%........................................................................................................................
Kemam$uan *eri*ada%
%........................................................................................................................(*% Bela.ar
Pengeta%uan anak tentang konse$ se%atCsakit :
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
• Perse$si anak ter%ada$ %os$italisasi :
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
.
U$a'a anak menjaga kese%atan :
...............................................................................................................................................................
................................................................................................................................................................
.
................................................................................................................................................................
Ke*utu%an inormasi anak tentang kese%atan :
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
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Buku EvaluasiStase Keperawatan Anak
Kemam$uan anak
%................................................................................................................................
G Pemeri#saan Indra
Penglihatan ,mata/
Pu$il %......................................................................................................................................
Releks -a%a'a%.................................................................................................................................
.....8isus %..........................................................................................................
............................,a$ang $andang%.................................................................................................................................
.....
Pendengaran ,telinga/
!angguan $endengaran
%............................................................................................................................
Peniuman ,hidung/
Bentuk %......................................................................................................................................
!angguan Pen-iuman%..............................................................................................................................
2 Re=le#s Primiti=
Moro %..........................................................................................................
............................
• Menole% %..........................................................................................................
............................
Meng%isa$ %..........................................................................................................
............................
Palmar %......................................................................................................................................
Pattela %..........................................................................................................
............................
Bal*inski %..........................................................................................................
............................
I $istem Kardi+>as#uler
T : mm#g
Nadi : ;/mnt
• &rama jantung
%.................................................................................................................................
.....• Bun'i jantung
%......................................................................................................................................
• ,etak i-tus -ordis
%......................................................................................................................................
N'eri dada
%......................................................................................................................................
4a$$ilar' reill
%.................................................................................................................................
.....
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Buku EvaluasiStase Keperawatan Anak
Akral %..........................................................................................................
............................
J $istem Re0r+du#si
(% Pengeta%uan tentang $erkem*angan re$roduksi...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
.
K Test &iagn+sti#
(% Pemeri#saan 'a5+rat+rium
Tanggal :???@ Jam :????%%
Jenis
Pemeri#saan
2asil 2arga
N+rmal
$atuan Inter0retasi hasil
)% Pemeri#saan Radi+l+gi@ MRI@ U$G@ EEG@ EG T $an:
Tanggal :???@ Jam :????%%
Jenis
Pemeri#saan
2asil Baaan Kesan Inter0retasi hasil
' Tera0i Medis
Jenis Tera0i Nama O5at &+sis Rute Fungsi
4airan &8
+*at $arenteral
+*at $eroral
+*at To$ikal
.................." ......../......./.......
5nama $era=at6
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ ((
7/25/2019 Format Pengkajian Stase Anak Untuk Mahasiswa - Copy
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Buku EvaluasiStase Keperawatan Anak
$TA$E KEPERAWATAN ANAK
PROGRAM PEN&I&IKAN PROFE$I NER$
UNI9ER$ITA$ RE$PATI OGAKARTA
ANA'I$A &ATA
Nama klien : ………………………………...
Umur :…………………………………
Ruang Ra=at :…………………………………
No. Register :………………………………...
iagnosa Medis :………………………………...
Alamat :…………………………………
TG'3JAM &ATA FOKU$ ETIO'OGI PROB'EM
TG'3JAM &ATA FOKU$ ETIO'OGI PROB'EM
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Buku EvaluasiStase Keperawatan Anak
TG'3JAM &ATA FOKU$ ETIO'OGI PROB'EM
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Buku EvaluasiStase Keperawatan Anak
PRIORITA$ &IAGNO$A
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Buku EvaluasiStase Keperawatan Anak
$TA$E KEPERAWATAN ANAK
PROGRAM PEN&I&IKAN PROFE$I NER$
UNI9ER$ITA$ RE$PATI OGAKARTA
RENANA TIN&AKAN
Nama #lien : ??????????? N+% Register:?????%%
??
Umur : ?????????? &iagn+sa Medis:
??????%%
Ruang :??????????? Alamat :
??????????%
No iagnosa
Ke$era=atan
Tujuan I Kriteria #asil &nterensi Rasionalisasi Nama/TT
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ (
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Buku EvaluasiStase Keperawatan Anak
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Buku EvaluasiStase Keperawatan Anak
$TA$E KEPERAWATAN ANAK
PROGRAM PEN&I&IKAN PROFE$I NER$
UNI9ER$ITA$ RE$PATI OGAKARTA
ATATAN PERKEMBANGAN
Nama #lien : ??????????? N+% Register :???????%%
Umur : ??????????? &iagn+sa Medis: ???????%%
Ruang :??????????? Alamat :???????%%
No ; Tanggal Jam &m$lementasi )aluasi Nama/TT
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ (F