Attachment 2

Praktek Profesi Keperawatan Anak Fakultas Keperawatan – Universitas Andalas

PENGKAJIAN ANAK Nama Mahasiswa

: ________________

No. BP

: ________________

Tempat Praktek

: ________________

I.

Tanggal Pengkajian : __________________ Tanggal Masuk RS : __________________ No. RM : __________________

IDENTITAS DATA

Nama Anak BB/TB Tanggal Lahir/Usia Jenis Kelamin Pendidikan Anak Anak ke

: ________________ : ________________ : ________________ : ________________ : ________________ : ________________

Nama Ibu Pekerjaan Pendidikan Agama Alamat Diagnosa Medis

: __________________ : __________________ : __________________ : __________________ : __________________ : __________________

II. KELUHAN UTAMA (ALASAN MASUK RUMAH SAKIT) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ III. RIWAYAT KEHAMILAN DAN KELAHIRAN a. Prenatal : ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ b. Intranatal : ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ c. Postnatal : ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ IV. RIWAYAT KESEHATAN DAHULU a. Penyakit yang diderita sebelumnya: __________________________________________________________________ __________________________________________________________________ _________________________________________________________________ b. Pernah dirawat di RS: __________________________________________________________________ __________________________________________________________________ Silvina Esa Putri, S.Kep

Praktek Profesi Keperawatan Anak Fakultas Keperawatan – Universitas Andalas

c. Obat-obatan yang pernah digunakan: __________________________________________________________________ _________________________________________________________________ d. Alergi: __________________________________________________________________ _________________________________________________________________ e. Kecelakaan: __________________________________________________________________ _________________________________________________________________ f. Riwayat Imunisasi: __________________________________________________________________ __________________________________________________________________ _________________________________________________________________ V. RIWAYAT KESEHATAN SAAT INI ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ VI. RIWAYAT KESEHATAN KELUARGA ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Genogram

Keterangan :

VII. RIWAYAT TUMBUH KEMBANG a. Kemandirian dan Bergaul :

Silvina Esa Putri, S.Kep

Praktek Profesi Keperawatan Anak Fakultas Keperawatan – Universitas Andalas

___________________________________________________________________ ___________________________________________________________________ b. Motorik Kasar : ___________________________________________________________________ ___________________________________________________________________ c. Motorik Halus : ___________________________________________________________________ ___________________________________________________________________ d. Kognitif dan Bahasa : ___________________________________________________________________ ___________________________________________________________________ e. Psikososial : ___________________________________________________________________ ___________________________________________________________________ f. Lain-lain : ___________________________________________________________________ VIII. RIWAYAT SOSIAL a. Yang mengasuh Klien: ___________________________________________________________________ ___________________________________________________________________ b. Hubungan dengan Anggota Keluarga: ___________________________________________________________________ ___________________________________________________________________ c. Hubungan dengan Teman Sebaya: ___________________________________________________________________ ___________________________________________________________________ d. Pembawaan secara Umum: ___________________________________________________________________ ___________________________________________________________________ e. Lingkungan Rumah : ___________________________________________________________________ ___________________________________________________________________

Silvina Esa Putri, S.Kep

Praktek Profesi Keperawatan Anak Fakultas Keperawatan – Universitas Andalas

IX.

PEMERIKSAAN FISIK a. Keadaan Umum b. TB/BB c. Kepala

: _________________________________ : _________cm/___________kg

-

Lingkar Kepala

: _________cm

-

Rambut

Kebersihan

:

Warna

:

Tekstur

:

Distribusi Rambut

:

Kuat/Mudah Tercabut : Simetris/Tidak Simetris

:

d. Mata -

Sklera

:

-

Konjunctiva

:

-

Palpebra

:

-

Pupil

Ukuran

:

Bentuk

:

Reaksi Cahaya : Simetris/Tidak Simetris

:

e. Telinga -

Serumen

- Pendengaran f. Hidung

: : : Simetris/Tidak Simetris

-

Septum

:

-

Sekret

:

- Polip g. Mulut

:

-

Kebersihan

:

-

Warna Bibir

:

-

Kelembapan

:

Lidah

:

Gigi h. Leher

:

-

Kelenjar Getah Bening

:

-

Kelenjar Tiroid

:

- JVP i. Dada

:

Silvina Esa Putri, S.Kep

Praktek Profesi Keperawatan Anak Fakultas Keperawatan – Universitas Andalas

-

Inspeksi

- Palpasi j. Jantung

: :

-

Inspeksi

:

-

Palpasi

:

- Auskultasi k. Paru-Paru

:

-

Inspeksi

:

-

Palpasi

:

-

Perkusi

:

- Auskultasi l. Perut

:

-

Inspeksi

:

-

Palpasi

:

-

Perkusi

:

- Auskultasi m. Punggung n. Ekstremitas -

Kekuatan dan Tonus

: Bentuk : :

Otot -

Reflek-reflek

o. Genitalia p. Kulit

:

Bawah : :

-

Warna

:

-

Turgor

:

-

Integritas

:

- Elastisitas q. Pemeriksaan Neurologis X.

Atas

: :

PEMERIKSAAN TUMBUH KEMBANG a. DDST _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ b. Status Nutrisi

Silvina Esa Putri, S.Kep

Praktek Profesi Keperawatan Anak Fakultas Keperawatan – Universitas Andalas

_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ XI. PEMERIKSAAN PSIKOSOSIAL (Erick H. Erickson) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ XII. PEMERIKSAAN SPIRITUAL ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ XIII. PEMERIKSAAN PENUNJANG Pemeriksaan Diagnostik

Data Laboratorium

XIV. KEBUTUHAN DASAR SEHARI-HARI No 1

Jenis Kebutuhan Makan

2

Minum

3

Tidur

4

Mandi

Di Rumah/sebelum sakit

Di Rumah sakit

Silvina Esa Putri, S.Kep

Praktek Profesi Keperawatan Anak Fakultas Keperawatan – Universitas Andalas

5

Eliminasi

6

Bermain

XV. RINGKASAN RIWAYAT KEPERAWATAN ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

XVI. ANALISA DATA No.

Data

Patofisiologi

Masalah

Silvina Esa Putri, S.Kep

Praktek Profesi Keperawatan Anak Fakultas Keperawatan – Universitas Andalas

XVII. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS ___________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Silvina Esa Putri, S.Kep

Praktek Profesi Keperawatan Anak Fakultas Keperawatan – Universitas Andalas

RENCANA ASUHAN KEPERAWATAN NO

Diagnosa Keperawatan

Tujuan dan Kriteria Hasil (NOC)

Intervensi (NIC)

Silvina Esa Putri, S.Kep

Praktek Profesi Keperawatan Anak Fakultas Keperawatan – Universitas Andalas

Silvina Esa Putri, S.Kep

Praktek Profesi Keperawatan Anak Fakultas Keperawatan – Universitas Andalas

CATATAN PERKEMBANGAN Nama

No

:

Hari/Tanggal

No RM

Diagnosa

Implementasi

:

Evaluasi

Paraf

Dini Aprisupitha, S.Kep 1741313058