Askep Tumbuh Kembang Anak.docx

ASUHAN KEPERAWATAN TUMBUH KEMBANGANAK STIKESHARAPANBANGSA PURWOKERTO

NamaMahasiswa

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

NIM

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

TempatPraktik/Ruang

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

TanggalPengkajian

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

I.

PENGKAJIAN A. Identitas 1.

2.

Identitaspasien Namapasien

:

Tanggallahir

:

Agama

:

Sukubangsa

:

Pendidikan

:

Alamat

:

No. rekammedis

:

Identitasorangtua: NamaAyah/Ibu : Agama Ayah/Ibu

:

SukuAyah/Ibu: PendidikanAyah/Ibu

:

PekerjaanAyah/Ibu

:

Alamat : B. Riwayat Tumbuh Kembang 1.

Riwayat Pertumbuhan ................................................................................................................................. .................................................................................................................................

2.

Riwayat Perkembangan (ceritakan kejadian-kejadian penting: pertama kali mengangkat kepala, berguling, duduk sendiri, berdiri, berjalan, berbicara/kata2 bermakna ataukalimat, gangguan mental perilaku atau gangguan perkembangan yang lain) ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. .................................................................................................................................

C. Riwayat Penyakit Dahulu ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... D. Genogram (3 generasi)

(Tuliskan data dari keluarga yang mengalami keterlambatan tumbuh kembang)

E. RiwayatObstetri 1.

RiwayatKehamilan ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. .................................................................................................................................

2.

Riwayat Persalinan ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. .................................................................................................................................

3.

Riwayat Post Natal ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. .................................................................................................................................

a.

b.

Neonatal (0-28hari): APGARskor

:

Asfiksia

:

Ikterik

:

Sianosis

:

Reflekprimitif

:

Usia lebih dari 1 bulan:

Apakah mengalami kejang? Demam? Sakit berat lainnya?

II. PELAKSANAANPEMERIKSAAN TUMBUH KEMBANG DAN INTERPRETASI HASIL A. PEMERIKSAANPERTUMBUHAN Kriteriapengukuran Hasilpengukuran Interpretasihasil BeratBadan Tinggi/PanjangBadan LingkarLenganAtas LingkarKepala LingkarDada Kesimpulanhasilantropometri: ........................................................................................ B. PELAKSANAAN DDST Usiakronologisanak : KondisisaatpemeriksaanDDST : Kriteriapenilaian Hasilpengukuran Interpretasihasil Personal sosial Adaptif-motorikhalus Adaptif-motorikkasar Bahasa Kesimpulanhasilpemeriksaan DDST: .............................................................................

III. ANALISA DATA Data yang diperoleh

Problem

Etiologi

IV. PRIORITAS DIAGNOSA KEPERAWATAN A. ......................................................................................................................................... B. ......................................................................................................................................... C. ......................................................................................................................................... V. PERENCANAAN DX Kep

Tujuan dan Kriteria Hasil

Intervensi

Paraf

VI. PELAKSANAAN DX Kep

Hari/tgl /jam

Tujuan dan Kriteria Hasil

Intervensi

Paraf

VII.EVALUASI Hari/tgl

Diag. Kep

Evaluasi

Paraf