232553215-Format-Asuhan-Keperawatan-Anak.doc

7/26/2019 232553215-Format-Asuhan-Keperawatan-Anak.doc

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

!m"r : ..................................................................................................

#enis $elamin : ..................................................................................................S"k" %angsa : ..................................................................................................

&ahasa 'ang dimengerti : ..................................................................................................

Agama : ..................................................................................................

Nama A'ah I%" wali : ..................................................................................................

Pendidikan a'ahi%"wali : ..................................................................................................

Pekerjaan a'ahi%"wali : ..................................................................................................

Alamat no telp : ..................................................................................................

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

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

II. $E(!)AN !TAMA

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

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

III. RI*A+AT $ESE)ATAN SAAT INI

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

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

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

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I,. RI*A+AT $ESE)ATAN MASA (A(!

a. Pre natal

Saat hamil : I%" merokok : -'a tidak

I%" min"m min"man keras : -'a tidak

%. Intra dan post natal

Intranatal

/ (ama persalinan : ....................................................................................

/ Saat persalinan : premat"r mat"r serotin"s

/ $omplikasi persalinan : ....................................................................................

/ Terapi 'ang di%erikan : ....................................................................................

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

/ 0ara melahirkan : Per1aginam normal -

Dengan 1ak"m ekstraksi -

2perasi 3aesar - (ainn'a ......................................................................

/ Tempat melahirkan : R"mah Sakit -

R"mah &ersalin -

R"mah -

(ainn'a .......................................................................

Postnatal

/ !saha na4as : Dengan %ant"an -

Tanpa %ant"an -

/ $e%"t"han res"sitasi : .....................................................................................

/ Apgar skor : ...................................................................................../ &a'i langs"ng menangis : 'a tidak

/ Tangisan %a'i :k"atlemah lainn'a -se%"tkan...................................

/ 2%at5o%atan 'ang di%erikan setelah lahir............................................................

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

/ Tra"ma lahir : Ada - Tidak -

/ Narkosis : Ada - Tidak -

/ $el"arn'a "rin &A& : Ada - Tidak -

/ Respon 4isiologis ata" prilak" 'ang %ermakna :..................................................

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

3. Pen'akit 'ang pernah diderita : ...................................................................................

d. )ospitalisasi

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

e. 2perasi : ...................................................................................

4. Inj"ri ke3elakaan : ...................................................................................

g. Alergi : ................................................................................

...


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h. Im"nisasi : ...................................................................................

i. Pengo%atan : ................................................................................

...

,. RI*A+AT PERT!M&!)AN

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

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

,I. TIN6$AT PER$EM&AN6AN -6"nakan 7ormat DDST II dan lampirkan

a. Sosial.

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

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

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

%. Motorik hal"s

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

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

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

3. &ahasa

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

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

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

d. Motorik kasar

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

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

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

,II. RI*A+AT S2SIA(a. Pengas"h : .......................................................................

%. Pem%awaan se3ara "m"m : .......................................................................

3. )"%"ngan dengan anggota kel"arga : .......................................................................

d. )"%"ngan dengan teman se%a'a : .......................................................................

,III. RI*A+AT $E(!AR6A

a. Sosial ekonomi :

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

%. (ingk"ngan r"mah :

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

3. Pen'akit kel"arga :

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

6enogram


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I8. P2(A $ESE)ATAN

a. Pemeliharaan dan persepsi kesehatan

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

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

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

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

%. N"trisi -makanan dan 3airan

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

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

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

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

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

3. Akti4itas

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

.........................................................................................................................d. Tid"r dan istirahat

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

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

e. Eliminasi

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

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

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

4. Pola h"%"ngan

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

g. $oping.......................................................................................................................................

h. $ogniti4 dan persepsi

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

i. $onsep diri

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

j. Seks"al

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

k. Nilai

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

8. PEMERI$SAAN 7ISI$ -inspeksi 9 a"sk"ltasi

a. $eadaan "m"m : .....................................................................................................

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

TD : ...........mm)g Nadi : .......... menit RR :...menit

&& : ........... kg T& : .......... 3m S"h" %adan : ......... o 0

((A : ........... 3m ($ : .......... 3m (P : .......... 3m


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%. $"lit

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

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

3. $epala

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

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d. Mata

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

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

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

e. Telinga

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

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

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4. )id"ng

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

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

g. M"l"t

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

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

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

h. (eher

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

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

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

i. Dada

Par"5par"

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

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

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

#ant"ng

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

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

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

j. A%domen


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

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.

k. 6enetalia

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l. Ekstrimitas

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m. Ne"rologi

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

8I. PEMERI$SAAN DIA6N2STI$ PEN!N#AN6

8II. TERAPI +AN6 DIPER2(E) -$2(2M

8III. IN72RMASI (AIN -men3ak"p rangk"man kesehatan klien dari gi;i< 4isioterapis< dll


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8I,. ANA(ISIS DATA

DATA PEN+E&A& ETI2(26I MASA(A) PR2&(EM

DS :

D2 :


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8,. DIA6N2SA $EPERA*ATAN &ERDASAR$AN PRI2RITAS MASA(A)

=. ...

>.

?. ...

@. ...

8,I. REN0ANA $EPERA*ATAN

No N2 T"j"an dan $riteria Inter1ensi Rasional NamaTTD


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Diagnosa

$eperaw

atan

)asil -N20 -NI0

=


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8,II. 0ATATAN PER$EM&AN6AN

No Tanggal

jam

No.

Diagnosa

Implementasi E1al"asi proses

Respon

NamaTTD

= DS

D2

> DS

D2

? DS

D2

8,III. E1al"asi

No tanggal No.

Diagnosa

#am E1al"asi NamaTTD

= S

2

A

P

Denpasar< >..

Mahasiswa

232553215-Format-Asuhan-Keperawatan-Anak.doc

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