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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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Buku EvaluasiStase Keperawatan Anak
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 : .........................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
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Buku EvaluasiStase Keperawatan Anak
................................................................................................................
................................................................................................................
................................................................................................................
*% 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
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
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Buku EvaluasiStase Keperawatan Anak
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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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
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Buku EvaluasiStase Keperawatan Anak
,. Gen+gram
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
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Buku EvaluasiStase Keperawatan Anak
F Peng#a.ian (- Ke5utuhan &asar Manusia ,9irginia 2enders+n/
(% Perna0asan
a. -ingkar dada :
*. RR : ;/mnt
. 'rama % .................................................................d. $entuk dada % .................................................................e. Pengem*angan dada % .................................................................. $atuk % .................................................................
g. . 8okal #remitus % .................................................................r. Sianosis % .................................................................s. Kemam#uan anak % .................................................................
)% Nutrisi dan airan
a% Ri!a"at Nutrisi
& Pem*erian AS'
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
, Pem*erian susu ormula
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ ?
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Buku EvaluasiStase Keperawatan Anak
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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Buku EvaluasiStase Keperawatan Anak
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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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
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Buku EvaluasiStase Keperawatan 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 : @5
*. Kalau anak demam! a#a (ang dilakukan keluarga:
.....................................................................................................................................
. ..........................
.....................................................................................................................................
. ..........................
.....................................................................................................................................
. ..........................
. Ke*iasaan #enggunaan ki#as angin/A5:
.....................................................................................................................................
.
d% Kemam#uan anak
:.....................................................................................................
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
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Buku EvaluasiStase Keperawatan Anak
7% Men.aga #e5ersihan
Mandi
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
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Buku EvaluasiStase Keperawatan Anak
.....................................................................................................................................
. ..........................
.....................................................................................................................................
. ..........................
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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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
12/26
Buku EvaluasiStase Keperawatan Anak
. Kemam#uan
anak :.......................................................................................................
(
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Buku EvaluasiStase Keperawatan Anak
(*% 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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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
14/26
Buku EvaluasiStase Keperawatan Anak
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
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
15/26
Buku EvaluasiStase Keperawatan Anak
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 $an:
Tanggal :???@ Jam :????%%
Jenis
Pemeri#saan
2asil
Baaan
Kesan Inter0retasi hasil
' Tera0i Medis
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ &
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
16/26
Buku EvaluasiStase Keperawatan Anak
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$ &?
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
17/26
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 :...
Diagnosa Medis :...
Alamat :
TG'3JAM &ATA FOKU$ ETIO'OGI PROB'EM
TG'3JAM &ATA FOKU$ ETIO'OGI PROB'EM
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
18/26
Buku EvaluasiStase Keperawatan Anak
PRIORITA$ &IAGNO$A
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ &E
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
19/26
Buku EvaluasiStase Keperawatan Anak
$TA$E KEPERAWATAN ANAK
PROGRAM PEN&I&IKAN PROFE$I NER$
UNI9ER$ITA$ RE$PATI OGAKARTA
RENANA TIN&AKAN
Nama #lien : ??????????? N+% Register:?????%%?
Umur : ?????????? &iagn+sa Medis:?????
Ruang :??????????? Alamat :?????????
No Diagnosa
Ke#era=atan
Tujuan I Kriteria "asil 'nterBensi Rasionalisasi Nama/TTD
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
20/26
Buku EvaluasiStase Keperawatan Anak
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ ,@
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
21/26
Buku EvaluasiStase Keperawatan Anak
$TA$E KEPERAWATAN ANAK
PROGRAM PEN&I&IKAN PROFE$I NER$
UNI9ER$ITA$ RE$PATI OGAKARTA
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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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
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Buku EvaluasiStase Keperawatan Anak
$TA$E KEPERAWATAN ANAK
PROGRAM PEN&I&IKAN PROFE$I NER$
UNI9ER$ITA$ RE$PATI OGAKARTA
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ ,,
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
23/26
Buku EvaluasiStase Keperawatan Anak
ATATAN PERKEMBANGAN II
Nama #lien : ??????????? N+% Register :?????
Umur : ??????????? &iagn+sa Medis: ????
Ruang :??????????? Alamat :????
No D; Tanggal Jam 'm#lementasi )Baluasi Nama/TTD
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ ,0
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Buku EvaluasiStase Keperawatan Anak
$TA$E KEPERAWATAN ANAK
PROGRAM PEN&I&IKAN PROFE$I NER$
UNI9ER$ITA$ RE$PATI OGAKARTA
ATATAN PERKEMBANGAN III
Nama #lien : ??????????? N+% Register :?????Umur : ??????????? &iagn+sa Medis: ????
Program Pendidikan Profesi Ners FIKES Universitas espati !og"akarta#Unri"o$ ,9
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Buku EvaluasiStase Keperawatan Anak
Ruang :??????????? Alamat :????
No D; Tanggal Jam 'm#lementasi )Baluasi Nama/TTD
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7/24/2019 Format Pengkajian Stase Anak Untuk Mahasiswa 4
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Buku EvaluasiStase Keperawatan Anak