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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$  (

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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

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

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

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

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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% .................................................................

Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$  7

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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

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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$ 

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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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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

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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

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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 :

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

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

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

Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$  H

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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

%.................................................................................................................................

.....

Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$  (?

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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$  ((

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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

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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