format pengkajian keperawatan anak - bayi
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PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN ANAK/BAYI
STIKES HANG TUAH SURABAYA
Ruangan : ........................................Diagnosa medis : ........................................No. Register : ........................................Tgl/jam MRS : ........................................Tgl/jam pengkajian : ........................................
Anamnesa diperoleh dari :1. .....................................................................2. .....................................................................
I. IDENTITAS ANAKNama : .....................................................................................................................Umur/tanggal lahir : .....................................................................................................................Jenis kelamin : .....................................................................................................................Agama : .....................................................................................................................Golongan darah : .....................................................................................................................Bahasa yang dipakai : .....................................................................................................................Anak ke : .....................................................................................................................Jumlah saudara : .....................................................................................................................Alamat : .....................................................................................................................
II. IDENTITAS ORANG TUANama ayah : ........................................Umur : ........................................Agama : ........................................Suku/bangsa : ........................................Pendidikan : ........................................Pekerjaan : ........................................Penghasilan : ........................................Alamat : ........................................
Nama ibu : ........................................Umur : ........................................Agama : ........................................Suku/bangsa : ........................................Pendidikan : ........................................Pekerjaan : ........................................Penghasilan : ........................................Alamat : ........................................
III. KELUHAN UTAMA........................................................................................................................................................................................................................................................................................................................
IV. RIWAYAT PENYAKIT SEKARANG................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
V. RIWAYAT KEHAMILAN DAN PERSALINANA. Prenatal Care
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...................................................................................................................................................... Natal Care..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
B. Post Natal Care
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VI. RIWAYAT MASA LAMPAUA. Penyakit-Penyakit Waktu Kecil
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...................................................................................................................................................... Pernah Dirawat Di Rumah Sakit..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
B. Penggunaan Obat-Obatan..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
C. Tindakan (Operasi Atau Tindakan Lain)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
D. Alergi..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
E. Kecelakaan..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
F. Imunisasi..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
VII. PENGKAJIAN KELUARGAA. Genogram (Sesuai Dengan Penyakit)
B. Psikososial Keluarga..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
VIII.RIWAYAT SOSIALA. Yang Mengasuh Anak
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...................................................................................................................................................... Hubungan Dengan Anggota Keluarga............................................................................................................................................................................................................................................................................................................
B. Hubungan Dengan Teman Sebaya...........................................................................................................................................................................................................................................................................................................
Pembawaan Secara Umum............................................................................................................................................................................................................................................................................................................
IX. KEBUTUHAN DASARA. Pola Persepsi Sehat-Pelaksanaan Sehat
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......................................................................................................................................................B. Pola Nutrisi
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......................................................................................................................................................C. Pola Tidur
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......................................................................................................................................................D. Pola Aktivitas/Bermain
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......................................................................................................................................................E. Pola Eliminasi
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......................................................................................................................................................F. Pola Seksualitas Reproduktif
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......................................................................................................................................................G. Pola Peran Hubungan
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......................................................................................................................................................H. Pola Persepsi Diri – Konsep Diri
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......................................................................................................................................................I. Pola Kognitif Perseptual
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......................................................................................................................................................J. Pola Nilai Keyakinan
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......................................................................................................................................................K. Pola Koping Toleransi Stress
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X. KEADAAN UMUM (PENAMPILAN UMUM)A. Cara Masuk
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...................................................................................................................................................... Keadaan Umum............................................................................................................................................................................................................................................................................................................
XI. TANDA-TANDA VITALTensi : .......................................................................................................................................Suhu/nadi : .......................................................................................................................................RR : .......................................................................................................................................TB/BB : .......................................................................................................................................
XII. PEMERIKSAAN FISIKA. Pemeriksaan Kepala Dan Rambut
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...................................................................................................................................................... Mata..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
B. Hidung..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
C. Telinga..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
D. Mulut Dan Tenggorokan..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
E. Tengkuk Dan Leher..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
F. Pemeriksaan Thorax/Dada.................................................................................................................................................................................................................................................................................................................................................................................................................................................................. Paru........................................................................................................................................................................................................................................................................................................................................................................................................................................................... Jantung.....................................................................................................................................................................................................................................................................................................................................................................................................................................................
G. Punggung..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
H. Pemeriksaan Abdomen..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
I. Pemeriksaan Kelamin Dan Daerah Sekitarnya (Genetalia Dan Anus)
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......................................................................................................................................................J. Pemeriksaan Muskuloskeletal
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......................................................................................................................................................K. Pemeriksaan Neurologi
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......................................................................................................................................................L. Pemeriksaan Integumen
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XIII.TINGKAT PERKEMBANGANA. Adaptasi Sosial
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...................................................................................................................................................... Bahasa..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
B. Motorik Halus..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
C. Motorik Kasar..................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Kesimpulan Dan Pemeriksaan Perkembangan........................................................................................................................................................................................................................................................................................................................
XIV. PEMERIKSAAN PENUNJANGA. Laboratorium
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......................................................................................................................................................B. Rontgen
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......................................................................................................................................................C. Terapi
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Surabaya, .....................
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ANALISA DATA
Nama klien : ..............................................Umur : ..............................................
Ruangan/kamar : ..............................................No. register : ..............................................
MasalahPenyebabDataNo.
PRIORITAS MASALAH
Nama klien : .............................................. Umur : ..............................................
Ruangan/kamar : ..............................................No. register : ..............................................
No. Diagnosa KeperawatanTanggal Nama
PerawatDitemukan Teratasi
RENCANA KEPERAWATAN
No. Diagnosa Keperawatan Tujuan Intervensi Rasional
TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN
No. Tgl/jam Tindakan TT Tgl/jam Catatan Perkembangan TT