FORMAT ASUHAN KEPERAWATAN ANAK

POLTEKKES KEMENKES TANJUNGPINANG

A. Pengkajian
1. Pengumpulan Data
a. Bio Data
1) Nama :
2) Usia :
3) Alamat :
4) Jenis Kelamin :
5) Pendidikan :
6) Diagnosa Medis :

Identitas Penanggung Jawab

1) Nama :
2) Usia :
3) Jenis Kelamin :
4) Agama :
5) Pekerjaan :
6) Alamat :
7) Hubungan dengan Klien :

b. Riwayat Kesehatan
1) Keluhan Utama :
a) Keluhan utama saat masuk Rumah Sakit

b) Keluhan utama saat pengkajian

2) Riwayat Kesehatan Sekarang (PQRST)

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3) Riwayat Kesehatan Dahulu

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 4) Riwayat Kesehatan Keluarga

5) Riwayat Pertumbuhan dan perkembangan

a. Riwayat pertumbuhan

b. Riwayat Perkembangan

6) Riwayat Imunisasi

c. Data Biologis
1) Pola Aktifitas Sehari-hari
Pemeriksaan Sebelum Sakit Setelah Sakit
Nutrisi

Eliminasi
BAB :

BAK :

Istirahat dan Tidur

Personal Hygiene
2) Pemeriksaan Fisik

a) Keadaan Umum :

b) Tanda-tanda vital :

c) Pemeriksaan wajah
1. Mata

2. Hidung

3. Mulut

4. Telinga

d) Pemeriksaan kepala dan leher

1. Kepala

2. Leher

e) Pemeriksaan Thoraks / dada

1. Pemeriksaan paru
a. Inspeksi

b. Auskultasi

c. Palpasi

d. Perkusi

2. Pemeriksaan Jantung
a. Inspeksi

b. Auskultasi

c. Palpasi

d. Perkusi

f) Pemeriksaan Abdomen
1. Inspeksi

2. Auskultasi
 3. Palpasi

4. Perkusi

g) Pemeriksaan Ekstremitas
(a) Ekstremitas Atas

(b) Ekstremitas Bawah

h) Pemeriksaan Genetalia dan Rectal

1. Genetalia pria

2. Genetalia Wanita

d. Data Psikologis
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e. Data Sosial dan Spiritual

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f. Data Penunjang
1) Darah/urine/feses
Pemeriksaan Hasil Nilai Normal Interpretasi

2) Radiologi
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3) Terapi dan pengobatan

2. ANALISA DATA

Data Yang Menyimpang Etiologi Masalah

DS :

DO :
B. Diagnosa Keperawatan
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Perawat Yang Mengkaji
 RENCANA ASUHAN KEPERAWATAN

Nama Pasien : Diagnosa :

Tanggal :

Diagnosa Perencanaan
No.
Keperawatan Tujuan& Kriteria Hasil Intervensi Rasional
Keterangan : Tujuan berdasarkan P, Kriteria Berdasarkan S (Symptom), Intervensi Berdasarkan E
 TINDAKAN KEPERAWATAN DAN EVALUASI
Nama :
Diagnosa :
No Tanggal/ Jam No. DX Implementasi Respon Paraf
S:

O:

S:

O:

S:

O:
 CATATAN PERKEMBANGAN

Nama :
Diagnosa :

No Tanggal / Jam No.DX Catatan Perkembangan Paraf

S:

O:

A:

P:

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Perawat Yang Mengkaji