format anak

LAPORAN INDIVIDU

ASUHAN KEPERAWATAN ANAK PADA An. “R” DENGAN DCA

DI RUANG A5 RSKA 45 YOGYAKARTA

Laporan Ini Disusun Untuk Memenuhi Laporan Individu Program Pra Ners

Dalam Stase Keperawatan Anak

Disusun Oleh:

Maria Blandina Ebo Ria

KP.07.00372

PROGRAM STUDI NERS

SEKOLAH TINGGI ILMU KESEHATAN WIRA HUSADA

YOGYAKARTA

2012

Stase Keperawatan Anak/Program PraNers/STIKES Wira Husada Angkatan V/2012-2013

LEMBAR PERSETUJUAN

ASUHAN KEPERAWATAN ANAK PADA An. “R” DENGAN DCA

DI RUANG A5 RSKA 45 YOGYAKARTA

Disusun Oleh:

Maria Blandina Ebo Ria

KP.07.00372

Yogyakarta, Oktober 2012

Pembimbing Akademik; Pembimbing Lapangan;

(Ria Ratna Tri Widiastuti, S.Kep, Ns) ( )


ASUHAN KEPERAWATAN ANAK

PADA.....................................DENGAN........................................................................................................................DI RUMAH SAKIT KHUSUS

ANAK 45 YOGYAKARTA

Nama Mahasiswa : ……………………………………………………………………………………….......................................................................................................

NIM : ………………………………………………...................................................................................................................................................................

Tempat Praktek : …………………………………………………...............................................................................................................................................................

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

Tanggal Praktek :............................................................................................................................................................................................................................................

I. IDENTITAS DATA.

Nama Klien : …………………………………………………………..........................................................................................................................

No. Rekam Medis : …………………………………………….............................................................................................................................................

Tempat/tgl lahir : ………………………………………………..........................................................................................................................……….....

Jenis Kelamin : …………………………………………………………….......................................................................................................................

Suku bangsa : …………………………………………………..…………......................................................................................................................

Bahasa yang dimengerti : ………………………………………………… ………..........................................................................................................................

Agama :………………………………………………...…………........................................................................................................................

Nama Ayah/Ibu/Wali : ………………………………………………...…………........................................................................................................................

Pekerjaan Ayah/Ibu/wali : ………………………………………………...………….....................................................................................................................

Pendidikan : …………………………………………………..…………......................................................................................................................

Alamat Ayah/ibu/wali : …………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………...

Diagnosa medis :....................................................................................................................................................................................................................

II. KELUHAN UTAMA……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

III. RIWAYAT KELUHAN SAAT INI……………………………………………………………………………………………………………………………………………………………………………………………………………

………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………

IV. RIWAYAT KESEHATAN MASA LALU


a. Prenatal : ………………………………………………………………………………………………………………………………………………………………………….............

……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………...........................

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

b. Intra dan post natal : ………………………………………………………………………………………………………………………………………...........................

………………………………………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………..............

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

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

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

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

c. Penyakit yang pernah diderita……………………………………………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………….

d. Hospitalisasi/tindakan operasi……………………………………………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………………………………………………………………………………..

e. Injury/kecelakaaan………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………….

f. Alergi………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………..

g. Imunisasi dan tes laboratorium………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………….

h. Pengobatan………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

V. RIWAYAT PERTUMBUHAN


………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

VI. PENGKAJIAN TINGKAT PERKEMBANGAN SAAT INI ( gunakan format

Denver/DDST )

a. Personal social…………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………

b.Adaptif Motorik halus…………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………

c. Bahasa…………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………… ……………..

d.Motorik kasar…………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………

Inteprestasi…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………................................................

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

VII. RIWAYAT SOSIAL

a. Pengasuh………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

b. Hubungan dengan anggota keluarga………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………….

c. Hubungan dengan teman sebaya………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………….

d. Pembawaan secara umum………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………….

VIII. RIWAYAT KELUARGA

a. Sosial Ekonomi


………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

b. Lingkungan rumah………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………….

c. Penyakit keluarga………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

d. Genogram

IX. POLA KESEHATAN

a. Pemeliharaan dan persepsi terhadap kesehatan……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

................................................................................................................................................................................................................................................................................................……

b. Nutrisi (makanan an cairan)……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

................................................................................................................................................................................................................................................................................................…….

................................................................................................................................................................................................................................................................................................…….

................................................................................................................................................................................................................................................................................................…….

……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………….....................................

c. Aktivitas……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

d. Tidur dan istirahat……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

................................................................................................................................................................................................................................................................................................……


e. Eliminasi……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………

................................................................................................................................................................................................................................................................................................…….

................................................................................................................................................................................................................................................................................................…….

f. Pola hubungan……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

g. Koping ……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

h. Kognitif dan persepsi……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………....

……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………

i. Seksual……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………...

................................................................................................................................................................................................................................................................................................…….

j. Nilai……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………...

X. PEMERIKSAAN FISIK

a. Keadaan umum

Tingkat kesadaran : ……………………………………………….........................................................................................................................................

Nadi :..…………………….......... Suhu :.…………………….… RR :.. ……………………… TD : ………………………..........................

BB :...……………………… TB : ………………………... LLA : ………………………..... LK :……………………….......................

LP :..............................................

b. Kepala……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

c. Dada……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

d. Abdomen…………………………………………………………………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………………………………………….

e. Genetalia……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….


f. Ektremitas……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………...

……………………………………………………………………………………………………………………………………………………………………………………………………..

g. Neurology……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………..

XI. PEMERIKSAAN DIAGNOSTIK PENUNJANG……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………………

XII. INFORMASI LAIN…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………

XIII. ANALISA DATA

DATA MASALAH ETIOLOGI

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………

……………………………………………………

……………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………


…………………….

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

…………………….

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

…………………….

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

…………………….

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

…………………….

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

…………………………….

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

…………………………….

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

…………………………………………………….................................................

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

……………………………………………………

……………………………………………………

………….

……………………………………………………

……………………………………………………

……………………………………………………

……………………………………………………

……………………………………………………

………….

……………………………………………………

……………………………………………………

……………………………………………………

……………………………………………………

……………………………………………………

………….

……………………………………………………

……………………………………………………

……………………………………………………

……………………………………………………

……………………………………………………

………….

……………………………………………………

……………………………………………………

………………………………………......................

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

…………………………………………………

…………………………………………………

……………………….

…………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………

……………………….

…………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………

……………………….

…………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………

…………………….

…………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………

……………………….

…………………………………………………

…………………………………………………

…………………………………………………

………………………………….

…………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………

……………………….

…………………………………………………

…………………………………………………

…………………………………………………

………………………………….

…………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………

…………………………………………………

……………………….

…………………………………………………

…………………………………………………

………………………………………………….

…………………………………………………

…………………………………………………


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

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

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

........

………………………………………………………………………………….

…………………………………………………………………….........................

...

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

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

……………………………………………………

…………………………….………………………

………………………………………………….

…………………………………………………

…………………………………………………

………………………………………………….

…………………

XIV. PRIORITAS MASALAH

1. ...................................................................................................................................................................................................................................................................................................

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

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

2. .……………………………………………………………………………………………………………………………………………………………………………….………..

…………………………………………………………………………………………………………………………………………………………………………………….

………………………………………………..……………………………………………………………………………………………………………………………………….……..

3. .………………………………………………………………………………………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………………………………………………………………………….

…………………………………………..……………………………………………………………………………………………………………………………………………...

4. .………………………………………………………………………………………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………………………………………………………………………….

…………………………………………..……………………………………………………………………………………………………………………………………………...

5. .………………………………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………………….

……………………………………………..……………………………………………………………………………………………………………………………………………..


XV. RENCANA KEPERAWATAN

Nama Klien : ……………………………………………………………………………………….. Nama Mahasiswa :............................................................................................................................................................................

Ruang : ………………………………………………………………………………………... NIM :............................................................................................................................................................................

Diagnosa Medis : ………………………………………………………………………………………. Paraf :………………………………………………………………………………………........................................

NODIAGNOSA

KEPERAWATAN/MASALAH KOLABORATIF

TUJUAN DAN KRITERIA HASIL (NOC)

INTERVENSI(NIC)

RASIONAL

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

……......................................................................................

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

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

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

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

.

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

……………………………………………………..

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

…………..............................................................................................

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

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

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

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

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

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

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

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

........

……………………………........................................................................................................

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

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

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

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

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

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

…................................................................................................................................................

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

.

…………………………………………………………………………………………

………………...................................................................................................................

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

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

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

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

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

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

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

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


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

NODIAGNOSA

KEPERAWATAN/MASALAH KOLABORATIF

TUJUAN DAN KRITERIA HASIL (NOC)

INTERVENSI(NIC)

RASIONAL

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

……......................................................................................

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

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

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

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

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

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

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

.

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

……………………………………………………..

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

………………………………………………………………………

…………..............................................................................................

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

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

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

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

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

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

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

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

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

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

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

........

……………………………........................................................................................................

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

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

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

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

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

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

…................................................................................................................................................

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

.

…………………………………………………………………………………………

………………...................................................................................................................

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

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

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

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

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

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

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

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

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

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

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

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


...........

……………………………………......................................

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

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

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

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

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

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

.......

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

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


XVI. CATATAN PERKEMBANGAN

DIAGNOSA KEPERAWATAN/MASALAH KOLABORATIF

Hari, Tanggal, & Jam IMPLEMENTASI EVALUASINama &

paraf.............................................................................

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

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

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

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

…………………………………….....................

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

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

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

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

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

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

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

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

…………………………………….....................

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

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

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

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

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

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

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

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

…………………………………….....................

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

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

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

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

……………………………………...............................

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

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

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

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

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

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

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

……………………………………...............................

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

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

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

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

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

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

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

……………………………………...............................

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

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

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

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

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

……………………………………....................................................................................................................

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

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

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

……………………………………....................................................................................................................

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

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

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

……………………………………....................................................................................................................

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

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

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

……………………………………....................................................................................................................

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

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

...................................................................................................................................…………..

…………………………....................................................................................................................................

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

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

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

……………………………………....................................................................................................................

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

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

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

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

…………………………………….........................................................................

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

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

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

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

..

…………………………………….........................................................................

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

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

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

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

..

…………………………………….........................................................................

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

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

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

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

...

…………………………………….........................................................................

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

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

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

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

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

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

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

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

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

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

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

.....

……………………

………………...........

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

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

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

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

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

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

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

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

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

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

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

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


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

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

..……………………………………..

DIAGNOSA KEPERAWATAN/MASALAH KOLABORATIF

Hari, Tanggal, & Jam IMPLEMENTASI EVALUASINama &

paraf.............................................................................

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

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

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

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

…………………………………….....................

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

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

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

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

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

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

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

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

…………………………………….....................

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

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

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

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

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

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

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

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

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

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

……………………………………...............................

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

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

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

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

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

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

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

……………………………………...............................

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

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

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

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

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

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

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

……………………………………...............................

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

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

……………………………………....................................................................................................................

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

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

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

……………………………………....................................................................................................................

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

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

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

……………………………………....................................................................................................................

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

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

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

……………………………………....................................................................................................................

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

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

...................................................................................................................................…………..

…………………………....................................................................................................................................

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

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

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

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

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

…………………………………….........................................................................

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

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

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

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

..

…………………………………….........................................................................

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

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

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

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

..

…………………………………….........................................................................

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

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

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

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

...

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

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

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

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

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

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

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

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

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

.....

……………………

………………...........

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

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

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

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

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

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

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

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

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


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

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

…………………………………….....................

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

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

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

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

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

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

……………………………………....................................................................................................................

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

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

…………………………………….........................................................................

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

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

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

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

..……………………………………..

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

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

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


format anak

Documents