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ASUHAN KEPERAWATAN TUMBUH KEMBANG PADA AN. A DENGAN ALAT UKUR TUMBUH KPSP DI PUSKESMAS SRONDOL

Disusun untuk Memenuhi Tugas Stase Keperawatan Anak Tingkat Profesi Pembimbing Akademik: Ns. Meira Erawati, MSi Med Pembimbing Klinik: Ns. Sugiyarto, S.KM, S.Kep

Disusun Oleh : Nur Ali Hidayat 22020118210052

PROGRAM PENDIDIKAN PROFESI NERS ANGKATAN XXXII DEPARTEMEN KEPERAWATAN FAKULTAS KEDOKTERAN UNIVERSITAS DIPONEGORO 2018

BAB I PENDAHULUAN

A. Latar Belakang

Pertumbuhan (Growth) berkaitan dengan masalah perubahan dalam besar, jumlah, ukuran atau dimensi tingkat sel organ maupun individuyang bisa diukur dengan ukuran berat (gram, pound, kilogram), ukuran panjang (cm,meter), umur tulang dan keseimbangan metabolik (retensi kalsium dan nitrogen tubuh). Perkembangan (development) adalah bertambahnya kemampuan (Skill) dalam struktur dan fungsi tubuh yang lebih kompleks dalam pola yang teratur dan dapat diramalkan, sebagai hasil dari proses pematangan. Walaupun demikian seorang anak dalam banyak hal tergantung kepada orang dewasa, misalnya mengkonsumsi makanan, perawatan, bimbingan, perasaan aman, pencegahan penyakit dan sebagainya. Oleh karena itu semua orang-orang yang mendapat tugas mengawasi anak harus mengerti persoalan anak yang sedang tumbuh dan berkembang.

B. Tujuan 1. Tujuan Umum Mahasiswa mampu memberikan asuhan keperawatan tumbuh kembang pada An.A . 2. Tujuan Khusus a. Mengetahui hasil pengkajian tumbuh kembang An. A b. Mengetahui masalah keperawatan yang muncul pada An.A c. Menentukan diagnosa keperawatan yang muncul pada An.A d. Membuat rencana tindakan keperawatan yang diberikan pada An.A e. Melakukan implementasi tindakan keperawatan kepada An.A f. Melakukan evaluasi tindakan keperawatan kepada An. A

BAB III PROSES ASUHAN KEPERAWATAN PADA ANAK I.

PENGKAJIAN A. Data Demografi 1. Klien/Pasien

2.

a

Tanggal pengkajian

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

b

Tanggal masuk

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

c

Ruangan

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

d

Identitas 

Nama



Tanggal lahir/umur: .........................................................................



Jenis kelamin

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



Agama

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



Suku

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



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



Penanggung jawab: ..........................................................................

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

Orang Tua/ Penanggung Jawab a.

Nama

: ………………………......................

b.

Hubungan dengan klien

: …………………………..................

c.

Suku

: ……………………….......................

d.

Agama

: …………………………...................

e.

Alamat

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

f.

No. telepon

: …………………...............................

B. Keluhan Utama …………………………………………………………………………………………… ……………………………………………………………………………………… C. Riwayat Klien

1.

Riwayat penyakit penyakit sekarang:……………………...................................... ……………………………………………………......................................................... .............................................................................................................................

2.

Riwayat klien sebelumnya : ...................................................................................................................................

3. Riwayat kehamilan (ANC, masalah kesehatan selama kehamilan, dll) : ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ..................................................................................................... 4. Riwayat persalinan (jenis persalinan, penolong persalinan, apgar skor, penyulit persalinan, dll) : ………………………………………………………………………………………… ………………………………………………………………………………………… ……................................................................................................................................. ......................................................................................................................................... ......................................................................................................................................... ................................................................................................. 5. Riwayat imunisasi (berikan tanda silang pada imunisasi yang sudah dilakukan) 

Hepatitis B



Hepatitis B II

 Hepatitis B III



Polio I

 Polio II



Polio III

 Polio IV



DPT I

 DPT II



DPT III

 Campak



LAINNYA,sebutkan…….................................................................

I

 BCG

6. Riwayat alergi

:

……………..................................................................................................................... ............................................................................................................................. …………………………………………………………………………………… 7. Riwayat pemakaian obat-obatan : ...…….............................................................................................................................. ............................................................................................................................. ……………………………………………………………………………………...

D. Riwayat Kesehatan Keluarga 1.

Riwayat penyakit dalam keluarga: ………………………………………………........…...........………………………… …………………………………………………………….............................

2.

Genogram

Keterangan gambar :

: laki-laki

: klien

: perempuan

: meninggal

: tinggal dalam satu rumah

E. Pengkajian tumbuh kembang (Lampirkan Format Denver II atau KPSP): Motorik halus: ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... .............................................................................. Motorik kasar: ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ............................................................................ Bahasa : ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................

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

Personal sosial: ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ...........................................................................

ANALISA DATA 2. N O

DATA

PROBLEM

ETIOLOGI

10.

PROBLEM LIST TGL/JAM

NO

TGL/JAM DX KEP

DITEMUKAN

TTD

TTD TERATASI

3. RENCANA KEPERAWATAN TGL /JAM NO

INTERVENSI DX KEP

TUJUAN

TINDAKAN

TTD

4. IMPLEMENTASI TGL NO

DX KEP

IMPLEMENTASI /JAM

RESPON

TTD

5. EVALUASI (perkembangan setiap hari dalam bentuk SOAP) 6. N TGL/JAM O

DX KEP

EVALUASI

TTD