format pengkajian keperawatan anak - bayi

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PENGKAJIAN KEPERAWATAN ASUHAN KEPERAWATAN ANAK/BAYI STIKES HANG TUAH SURABAYA Ruangan : ................. ....................... Diagnosa medis : .................. ...................... No. Register : .................. ...................... Tgl/jam MRS : .................. ...................... Tgl/jam pengkajian : .................. ...................... Anamnesa diperoleh dari : 1. ............................ ............................. ............ 2. ............................ ............................. ............ I. IDENTITAS ANAK Nama : ................................................ ................................................................. .... Umur/tanggal lahir : .................................................. ................................................................. .. Jenis kelamin : .................................................. ................................................................. .. Agama : ................................................ ................................................................. .... Golongan darah : .................................................. ................................................................. .. Bahasa yang dipakai : .................................................. ................................................................. .. Anak ke : .................................................. ................................................................. ..

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Page 1: Format Pengkajian Keperawatan Anak - Bayi

PENGKAJIAN KEPERAWATAN

ASUHAN KEPERAWATAN ANAK/BAYI

STIKES HANG TUAH SURABAYA

Ruangan : ........................................Diagnosa medis : ........................................No. Register : ........................................Tgl/jam MRS : ........................................Tgl/jam pengkajian : ........................................

Anamnesa diperoleh dari :1. .....................................................................2. .....................................................................

I. IDENTITAS ANAKNama : .....................................................................................................................Umur/tanggal lahir : .....................................................................................................................Jenis kelamin : .....................................................................................................................Agama : .....................................................................................................................Golongan darah : .....................................................................................................................Bahasa yang dipakai : .....................................................................................................................Anak ke : .....................................................................................................................Jumlah saudara : .....................................................................................................................Alamat : .....................................................................................................................

II. IDENTITAS ORANG TUANama ayah : ........................................Umur : ........................................Agama : ........................................Suku/bangsa : ........................................Pendidikan : ........................................Pekerjaan : ........................................Penghasilan : ........................................Alamat : ........................................

Nama ibu : ........................................Umur : ........................................Agama : ........................................Suku/bangsa : ........................................Pendidikan : ........................................Pekerjaan : ........................................Penghasilan : ........................................Alamat : ........................................

III. KELUHAN UTAMA........................................................................................................................................................................................................................................................................................................................

IV. RIWAYAT PENYAKIT SEKARANG................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

V. RIWAYAT KEHAMILAN DAN PERSALINANA. Prenatal Care

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

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

...................................................................................................................................................... Natal Care..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

B. Post Natal Care

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VI. RIWAYAT MASA LAMPAUA. Penyakit-Penyakit Waktu Kecil

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

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

...................................................................................................................................................... Pernah Dirawat Di Rumah Sakit..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

B. Penggunaan Obat-Obatan..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

C. Tindakan (Operasi Atau Tindakan Lain)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

D. Alergi..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

E. Kecelakaan..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

F. Imunisasi..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

VII. PENGKAJIAN KELUARGAA. Genogram (Sesuai Dengan Penyakit)

B. Psikososial Keluarga..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

VIII.RIWAYAT SOSIALA. Yang Mengasuh Anak

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

...................................................................................................................................................... Hubungan Dengan Anggota Keluarga............................................................................................................................................................................................................................................................................................................

Page 3: Format Pengkajian Keperawatan Anak - Bayi

B. Hubungan Dengan Teman Sebaya...........................................................................................................................................................................................................................................................................................................

Pembawaan Secara Umum............................................................................................................................................................................................................................................................................................................

IX. KEBUTUHAN DASARA. Pola Persepsi Sehat-Pelaksanaan Sehat

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

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......................................................................................................................................................B. Pola Nutrisi

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

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

......................................................................................................................................................C. Pola Tidur

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

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......................................................................................................................................................D. Pola Aktivitas/Bermain

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......................................................................................................................................................E. Pola Eliminasi

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......................................................................................................................................................F. Pola Seksualitas Reproduktif

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......................................................................................................................................................G. Pola Peran Hubungan

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......................................................................................................................................................H. Pola Persepsi Diri – Konsep Diri

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......................................................................................................................................................I. Pola Kognitif Perseptual

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......................................................................................................................................................J. Pola Nilai Keyakinan

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......................................................................................................................................................K. Pola Koping Toleransi Stress

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X. KEADAAN UMUM (PENAMPILAN UMUM)A. Cara Masuk

Page 4: Format Pengkajian Keperawatan Anak - Bayi

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...................................................................................................................................................... Keadaan Umum............................................................................................................................................................................................................................................................................................................

XI. TANDA-TANDA VITALTensi : .......................................................................................................................................Suhu/nadi : .......................................................................................................................................RR : .......................................................................................................................................TB/BB : .......................................................................................................................................

XII. PEMERIKSAAN FISIKA. Pemeriksaan Kepala Dan Rambut

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...................................................................................................................................................... Mata..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

B. Hidung..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

C. Telinga..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

D. Mulut Dan Tenggorokan..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

E. Tengkuk Dan Leher..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

F. Pemeriksaan Thorax/Dada.................................................................................................................................................................................................................................................................................................................................................................................................................................................................. Paru........................................................................................................................................................................................................................................................................................................................................................................................................................................................... Jantung.....................................................................................................................................................................................................................................................................................................................................................................................................................................................

G. Punggung..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

H. Pemeriksaan Abdomen..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

I. Pemeriksaan Kelamin Dan Daerah Sekitarnya (Genetalia Dan Anus)

Page 5: Format Pengkajian Keperawatan Anak - Bayi

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......................................................................................................................................................J. Pemeriksaan Muskuloskeletal

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......................................................................................................................................................K. Pemeriksaan Neurologi

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......................................................................................................................................................L. Pemeriksaan Integumen

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XIII.TINGKAT PERKEMBANGANA. Adaptasi Sosial

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...................................................................................................................................................... Bahasa..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

B. Motorik Halus..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

C. Motorik Kasar..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Kesimpulan Dan Pemeriksaan Perkembangan........................................................................................................................................................................................................................................................................................................................

XIV. PEMERIKSAAN PENUNJANGA. Laboratorium

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

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

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

......................................................................................................................................................B. Rontgen

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

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

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

......................................................................................................................................................C. Terapi

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

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

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

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

Surabaya, .....................

Page 6: Format Pengkajian Keperawatan Anak - Bayi

(...............................)

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ANALISA DATA

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

Ruangan/kamar : ..............................................No. register : ..............................................

MasalahPenyebabDataNo.

Page 8: Format Pengkajian Keperawatan Anak - Bayi

PRIORITAS MASALAH

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

Ruangan/kamar : ..............................................No. register : ..............................................

No. Diagnosa KeperawatanTanggal Nama

PerawatDitemukan Teratasi

Page 9: Format Pengkajian Keperawatan Anak - Bayi

RENCANA KEPERAWATAN

No. Diagnosa Keperawatan Tujuan Intervensi Rasional

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TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No. Tgl/jam Tindakan TT Tgl/jam Catatan Perkembangan TT

Page 11: Format Pengkajian Keperawatan Anak - Bayi