format pengkajian stase anak untuk mahasiswa 4

7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4

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Buku EvaluasiStase Keperawatan Anak

FORMAT PENGKAJIAN

KEPERAWATAN ANAK

Pengkajian Tanggal : ........................................................................................

Jam : ........................................................................................

Tanggal MRS : ........................................................................................Jam MRS : ........................................................................................

Ruang/Kelas : ........................................................................................

No. RM : ........................................................................................

A Identitas

I Pasien II Identitas Orang

Tua

Nama :

Umur :

Jenis Kelamin :

Agama :

Pendidikan :

Pekerjaan :

Alamat :

Diagnosa

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 $$ saat %amil :................................................ kg

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Pemeriksaan ke%amilan :

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

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

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

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

'munisasi TT :

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

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

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

Pen(akit (ang diderita saat %amil:

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

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

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

)mosi i*u #ada saat %amil:

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

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

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

Sika# i*u ter%ada# ke%amilan :

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

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

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

Penggunaan +*at :................................................................................................................

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

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

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

Perokok :

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

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

Alko%ol :

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

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

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

)% Intra Natal

Tanggal #ersalinan : .........................................................

Pukul : .........................................................

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

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

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

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

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

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

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


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

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

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

*% P+st Natal , )-.am /

a. APAR skor : .................................................................

*. $$- : .................................................................

. P$- : .................................................................

d. -K : .................................................................

e. -D : .................................................................

. Keadaan *a(i : .................................................................

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

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

-% Pen"a#it "ang 0ernah diderita

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

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

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

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

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

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

1% 2+s0italisasi3Tinda#an O0erasi

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

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

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

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

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

4% O5at6+5atan "ang diguna#an

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

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

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

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

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

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

7% Allergi

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

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

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

Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ 0


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8% Imunisasi dan tes la5+rat+rium

a. 'munisasi : 1 2 3a

1 2 Tidak

N

+

Jenis

immunisasi

4aktu

#em*erian

Reaksi setela%

#em*erian

&. $5

,. DPT

6'!''!'''7

0. Polio

6'!''!'''!'87

9. 5am#ak

. "e#atitis

*. Tes dara%/sreening test (ang #erna% dilakukan :

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

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

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

) Ri!a"at Keluarga(% Pen"a#it #eluarga

a. Pen(akit keturunan:

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

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

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

*. Kelainan kongenital :

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

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

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

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,. Gen+gram

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F Peng#a.ian (- Ke5utuhan &asar Manusia ,9irginia 2enders+n/

(% Perna0asan

a. -ingkar dada :

*. RR : ;/mnt

. 'rama % .................................................................d. $entuk dada % .................................................................e. Pengem*angan dada % .................................................................. $atuk % .................................................................

g. . 8okal #remitus % .................................................................r. Sianosis % .................................................................s. Kemam#uan anak % .................................................................

)% Nutrisi dan airan

a% Ri!a"at Nutrisi

& Pem*erian AS'

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

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

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

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

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

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

, Pem*erian susu ormula

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

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

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

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

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0 Pola #eru*a%an nutrisi tia# ta%a# usia sam#ai nutrisi saat ini

Usia Jenis Nutrisi'ama

Pem5erian

& @ ? $ulan

, ? &, $ulan

0 Saat ini5% Nutrisi $aat ini

Nasu makan % .................................................................


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e7 Pem*esaran 8U

%...................................................................................7 N(eri tekan

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

g78olume : /%ari%7Penggunaan alat *antu % ..................................................i7 Uretra %.....................................................................

.................j7 Ke*ersi%an genetalia% ...................................................k7angguan %...............................................................................

...........l)Kemam#uan anak

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

)/ BABa/


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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 : @5

*. Kalau anak demam! a#a (ang dilakukan keluarga:

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

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

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

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

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

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

. Ke*iasaan #enggunaan ki#as angin/A5:

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

.

d% Kemam#uan anak

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

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7% Men.aga #e5ersihan

Mandi


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

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

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

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

e. U#a(a orang tua untuk menega% edera:

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

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

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

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

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

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

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

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


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. Kemam#uan

anak :.......................................................................................................

(


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(*% 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 :

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

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

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

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

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

Kemam#uan anak

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

G Pemeri#saan Indra

Penglihatan ,mata/

Pu#il %......................................................................................................................................

Releks a%a(a

%...........................................................................................8isus %........................................................................................

.....................-a#ang #andang

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

Pendengaran ,telinga/

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angguan #endengaran

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

Peniuman ,hidung/

$entuk %.......................................................................................................

angguan Peniuman%..........................................................................................

2 Re=le#s Primiti=

Moro %......................................................................................................................................

Menole% %...............................................................................

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

Meng%isa# %......................................................................................................................................

Palmar %........................................................................................

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

Pattela %......................................................................................................................................

$al*inski %........................................................................................

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

I $istem Kardi+>as#uler

TD : mm"g

Nadi : ;/mnt

'rama jantung

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

$un(i jantung

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

-etak itus ordis

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

N(eri dada

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

5a##ilar( reill

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

Akral %.................................................................................................

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

J $istem Re0r+du#si

(% Pengeta%uan tentang #erkem*angan re#roduksi

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

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

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

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

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

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

Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ &9


15/26


K Test &iagn+sti#

(% Pemeri#saan 'a5+rat+rium

Tanggal :???@ Jam :????%%

Jenis

Pemeri#sa

an

2asil 2arga

N+rmal

$atua

n

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



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Jenis Tera0i Nama

O5at

&+sis Rute Fungsi

5airan '8

+*at #arenteral+*at #eroral

+*at To#ikal

..................! ......../......./.......

6nama #era=at7

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


17/26


$TA$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 :...

Diagnosa Medis :...

Alamat :

TG'3JAM &ATA FOKU$ ETIO'OGI PROB'EM

TG'3JAM &ATA FOKU$ ETIO'OGI PROB'EM



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PRIORITA$ &IAGNO$A

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


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RENANA TIN&AKAN

Nama #lien : ??????????? N+% Register:?????%%?

Umur : ?????????? &iagn+sa Medis:?????

Ruang :??????????? Alamat :?????????

No Diagnosa

Ke#era=atan

Tujuan I Kriteria "asil 'nterBensi Rasionalisasi Nama/TTD

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


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


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ATATAN PERKEMBANGAN I

Nama #lien : ??????????? N+% Register :?????

Umur : ??????????? &iagn+sa Medis: ????

Ruang :??????????? Alamat :????

No D; Tanggal Jam 'm#lementasi )Baluasi Nama/TTD

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22/26





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


23/26


ATATAN PERKEMBANGAN II

Nama #lien : ??????????? N+% Register :?????

Umur : ??????????? &iagn+sa Medis: ????

Ruang :??????????? Alamat :????


Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ ,0


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ATATAN PERKEMBANGAN III

Nama #lien : ??????????? N+% Register :?????Umur : ??????????? &iagn+sa Medis: ????

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Ruang :??????????? Alamat :????


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format pengkajian stase anak untuk mahasiswa 4

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