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PROGRAM STUDI S1 KEPERAWATANFAKULTAS KEPERAWATAN DAN KEBIDANAN
UNIVERSITAS NAHDLATUL ULAMA SURABAYAJl. Smea 57 Surabaya, Tlp. 031 828450, 8291920, Faks. (031)
8298582
FORMAT PENGKAJIAN KEPERAWATAN ANAK
I. DATA UMUMNama :…………………………………………………….Ruang : ………..…………………………………………..No. Register : …………………………………………………….Umur : …………………………………………………….Jenis Kelamin : …………………………………………………….Agama : …………………………………………………….Suku Bangsa : …………………………………………………….Bahasa : …………………………………………………….Alamat : …………………………………………………….Penanggung Jawab : ……………………………………………………Pendidikan Terakhir : ……………………………………………………Pekerjaan : ……………………………………………………Golongan Darah : ……………………………………………………Tanggal MRS : ……………………………………………………Tanggal Pengkajian : ……………………………………………………Diagnosa Medis : ……………………………………………………
II. DATA DASARKeluhan Utama:…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Alasan Masuk Rumah Sakit:…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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Riwayat Penyakit Sekarang:
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Upaya Yang Telah Dilakukan:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Terapi Yang Telah Diberikan:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Riwayat kesehatan dahalu : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Riwayat kesehatan keluarga : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Genogram :
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III. RIWAYAT ANTENATAL & POS NATAL1. Riwayat selama kehamilan
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
2. Obat-obatan yang digunakan………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3. Kecelakaan (jatuh) / tindakan yang pernah dilakukan …………………………………………………………………………….…………………………….……………………………………………….…………………………………………………………….……………….…………………………………………………………………………….…………………………………………
4. Tindakan oprasi …………………………………………………………………………….…………………………….……………………………………………….…………………………………………………………….……………….…………………………………………………………………………….……………………………….…………
5. Riwayat alergi …………………………………………………………………………….…………………………….……………………………………………….…………………………………………………………….……………….…………………………………………………………………………….……………………………….…………
6. Imunisasi…………………………………………………………………………….…………………………….……………………………………………….…………………………………………………………….……………….…………………………………………………………………………….……………………………….…………
IV. PENGKAJIAN PERKEMBANGAN (DDST ATAU KKA/KARTU KEMBANG ANAK)1. Motorik Kasar
…………………………………………………………………………….…………………………….……………………………………………….……...……………………………………………………….……………….……….…..………………………………………………………………….…………………………
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2. Motorik Halus…………………………………………………………………………….…………………………….……………………………………………….……...……………………………………………………….……………….…………...………………………………………………………………….…………………………
3. Personal Sosial…………………………………………………………………………….…………………………….……………………………………………….……...……………………………………………………….……………….…………..………………………………………………………………….………............…………
4. Bahasa…………………………………………………………………………….…………………………….……………………………………………….…………………………………………………………….……………….…………………………………………………………………………….………...……………………
Kesimpulan : ……………………………………………………………………………………………….
Tumbuh Kembang Untuk Anak Usia diatas 5 tahun sesuai dengan teori erik erikson, Sigmund fruid, kobler dll.
…………………………………………………………………………….…………………..………….………......…………………………………….…………………………………………………………….………………..……………………………………………………….…………………….…………………………………………....……………………………...……………………….…………………………….……………………………….….…………….…………………………………………………………….……………….…………….
Kesimpulan :………………………………………………………………………………….
V. RIWAYAT SOSIAL1. Pengasuh
…………………………………………………………………………….…………………………….………......…………………………………….………………………………………………………………….………………..………….………………………………………………………………………………………
2. Hubungan dengan anggota keluarga juga saudara…………………………………………………………………………….…………………………….………......…………………………………….………….………………………………………………….………………..
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…………………..………………………………………………………….…………………………
3. Pembawaan secara umum…………………………………………………………………………….…………………………….………......…………………………………….…………..………………………………………………….………………..………………...…………………………………………………………….……………………….…
4. Lingkungan rumah…………………………………………………………………………….………………………….………......…………………………………….…………….……………………………………………….………………..………………….………………………………………………………….……..……………………..
Kesimpulan : ………………………………………………………………………………...
VI. POLA FUNGSI KESEHATAN1. Persepsi keluarga terhadap kesehatan managemen kesehatan
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Kesimpulan :
2. Pola aktivitas dan latihan Kemampuan perawatan diri
Skor 0 : mandiri, 1 : dibantu sebagian, 2 : perlu bantuan orang lain, 3 : perlu bantuan orang lain dan alat, 4 : tergantung pada orang lain atau tidak mampu.
Aktivitas 0 1 2 3 4Mandi
Berpakaian
Eliminasi
Mobilisasi di tempat tidur
Pindah
Ambulasi
Naik tangga
Makan dan minum
Gosok gigi
Keterangan :………………………………………………………………......
…………………………………………………………………………………
3. Pola istirahat dan tidur :
KETERANGAN SEBELUM SAKIT SAAT SAKIT
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Jumlah jam tidur siang
Jumlah jam tidur malam
Pengantar tidur
Total tidur
Gangguan tidur
Kesimpulan (masalah) : …………………………………………………………………………………….…….………………………………………………………………………………………………………….…………………….........................................................................................................................................................……………………..
4. Pola Nutrisi – Metabolik 1) Berat badan sebelum sakit dan saat sakit
Tanggal pemeriksaan BB sebelum sakit BB saat sakit
2) Tinggi badan atau panjang badan………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3) Kebiasaan pemberian makanan
KETERANGAN SEBELUM SAKIT SAAT SAKITFrekuensiJenisPorsiTotal konsumsiKeluhan
5. Pola Kognitif dan Persepsi Sensori………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
6. Pola Konsep Diri………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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7. Pola Mekanisme Koping………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
8. Pola Fungsi Seksual – Reproduksi ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
9. Pola Hubungan – Peran ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
10. Pola Nilai dan Kepercayaan
KETERANGAN SEBELUM SAKIT SAAT SAKITNilai Khusus
Praktik ibadah
Pengetahuan tentang Praktik Ibadah selama sakit
11. Pola Aktivitas Bermain……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
VII. PEMERIKSAAN FISIK (DATA OBYEKTIF
1. Status Kesehatan UmumKeadaan / penampilan umum : GCS :Kesadaran : TB :BB sebelum sakit :BB saat ini :BB ideal :Perkembangan BB :Status Gizi :Tanda – tanda vital :
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TD :N :Suhu :RR :
4) Diit khusus…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
5) Tanda kecukupan nutrisi (NCHS atau menyesuaikan RS setempat)……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………..
Kesimpulan (masalah) : …………………………………………………………….
………………………………………………………………………………………..
Hidrasi
KETERANGAN INTAKE OUTPUT TANDA-TANDA DEHIDRASI
CAIRAN
Total Produksi UrinKesimpulam (masalah) : ………………………………………………………………………………………...............
…………………………………………………………………………………………………
5. Pola Eliminasi
Eliminasi Urin
KETERANGAN SEBELUM SAKIT SAAT SAKITFrekuensi
Pancaran
Jumlah
Bau
Warna
Perasaan setelah BAK
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Toal Produksi Urin
Eliminasi Alvi
KETERANGAN SEBELUM SAKIT SAAT SAKITFrekuensi
Konsistensi
Bau
Warna
2. Pemeriksaan fisik (B1-B6)1) B1 (Breathing)
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
2) B2 (Bleeding)..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3) B3 (Brain)..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4) B4 (Bladder)..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
5) B5 (Bowel)..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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6) B6 ( Bone).........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Pemeriksaan Diagnostik1) Laboraturium.
2) Radiologi
4. Terapi
1. oral
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
..............................................................................
2. Parenteral
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
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...............................................................................................................................................
..............................................................................
3. Lain-lain
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
..............................................................................
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ANALISA DATA
Nama Pasien : ................................................. No. RM : ...............................
Umur : ......................... Th/Bln Ruang : ................................
NO DATA (DS/DO) ETIOLOGI MASALAH
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DAFTAR DIAGNOSA KEPERAWATAN
Nama Pasien : ................................................. No. RM : ...............................
Umur : ......................... Th/Bln Ruang : ................................
NO DIAGNOSA KEPERAWATAN
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RENCANA TINDAKAN KEPERAWATAN
Nama Pasien : ................................................. No. RM : ...............................
Umur : ......................... Th/Bln Ruang : ................................
DIAGNOSA KEPERAWATAN : ............................................................................................................................................................................................................
.
No. Tujuan dan Kriteria Hasil Rencana Tindakan Rasional Paraf
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No. Tujuan dan Kriteria Hasil Rencana Tindakan Rasional Paraf
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TINDAKAN KEPERAWATAN
Nama Pasien: ................................................. No. RM : ...............................
Umur : ......................... Th/Bln Ruang : ................................
Tanggal/Jam No. Dx. T i n d a k a n Keperawatan Paraf
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CATATAN PERKEMBANGAN
Nama Pasien: ................................................. No. RM : ...............................
Umur : ......................... Th/Bln Ruang : ................................
Tanggal/Jam No. Dx. Catatan Perkembangan Paraf
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E V A L U A S I
Nama Pasien: ................................................. No. RM : ...............................
Umur : ......................... Th/Bln Ruang : ................................
Tanggal/Jam No. Dx. E v a l u a s i Paraf
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