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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 ANAK

Nama : .....................................................................................................................

Umur/tanggal lahir : .....................................................................................................................

enis kelamin : .....................................................................................................................

Agama : .....................................................................................................................!olongan darah : .....................................................................................................................

"ahasa #ang dipakai : .....................................................................................................................

Anak ke : .....................................................................................................................

umlah saudara : .....................................................................................................................

Alamat : .....................................................................................................................

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

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

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

VI. RIWAYAT MASA LAMPAU

A. %en#akit'%en#akit (aktu )e*il

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

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

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

%ernah Dira+at Di Rumah Sakit

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

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

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

". %enggunaan ,$at',$atan

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

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

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

&. Tindakan -,perasi Atau Tindakan ain

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

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

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

D. Alergi

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

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

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

0 )e*elakaan

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". 4u$ungan Dengan Teman Se$a#a

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

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

%em$a+aan Se*ara Umum

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

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

IX. KEBUTUHAN DASAR

A. %ola %ersepsi Sehat'%elaksanaan Sehat

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

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

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

". %ola Nutrisi

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

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

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

&. %ola Tidur

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

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

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

D. %ola Akti5itas/"ermain

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

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

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

0 %ola 0liminasi

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

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

)eadaan Umum

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

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

XI. TANDA-TANDA VITAL

Tensi : .......................................................................................................................................

Suhu/nadi : .......................................................................................................................................

RR : .......................................................................................................................................

T"/"" : .......................................................................................................................................

XII. PEMERIKSAAN FISIKA. %emeriksaan )epala Dan Ram$ut

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

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

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

Mata

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

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

......................................................................................................................................................". 4idung

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

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

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

&. Telinga

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

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

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

. %emeriksaan Muskuloskeletal......................................................................................................................................................

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

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

). %emeriksaan Neurologi

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

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

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

. %emeriksaan ntegumen......................................................................................................................................................

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

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

XIII.TINGKAT PERKEMBANGAN

A. Adaptasi Sosial

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

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

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

"ahasa

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

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

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

" Motorik 4alus

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-...............................

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ANALISA DATA

Nama klien : ..............................................

Umur : ..............................................

Ruangan/kamar : ..............................................

No. register : ..............................................

Masalah%en#e$a$DataNo.

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PRIORITAS MASALAH

Nama klien : ..............................................

Umur : ..............................................

Ruangan/kamar : ..............................................

No. register : ..............................................

No. Diagnosa )epera+atan Tanggal Nama

%era+atDitemukan Teratasi

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RENCANA KEPERAWATAN

No. Diagnosa )epera+atan Tujuan nter5ensi Rasional

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TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No. Tgl/jam Tindakan TT Tgl/jam &atatan %erkem$angan TT

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