format askep anak.doc

LAPORAN INDIVIDU

ASUHAN KEPERAWATAN ANAK PADA An. “T” DENGAN FEBRIS

DI RUANG KSB RSKA 45 YOGYAKARTA

Laporan Ini Disusun Untuk Memenuhi Laporan Individu Program Pra Ners

Dalam Stase Keperawatan Anak

Disusun Oleh:

I Kadek Dwi Satriya Wibawa

KP.07.00366

PROGRAM STUDI NERS

SEKOLAH TINGGI ILMU KESEHATAN WIRA HUSADA

YOGYAKARTA

2012

Stase Keperawatan Anak/Program PraNers/STIKES Wira Husada Angkatan V/2012-2013

LEMBAR PERSETUJUAN

ASUHAN KEPERAWATAN ANAK PADA An. “T” DENGAN FEBRIS

DI RUANG KSB RSKA 45 YOGYAKARTA

Disusun Oleh:

I Kadek Dwi Satriya Wibawa

KP.07.00366

Yogyakarta, November 2012

Pembimbing Akademik; Pembimbing Lapangan;

(Anida, S.Kep, Ns) (Sutanto, S.Kep, Ns, M.Kes.)

Penguji;

(Atik Badiah, S.Pd, S.Kp, M.Kes)


ASUHAN KEPERAWATAN ANAK

PADA.....................................DENGAN........................................................................................................................DI RUMAH SAKIT

KHUSUS ANAK 45 YOGYAKARTA

Nama Mahasiswa : ……………………………………………………………………………………….......................................................................................................

NIM : ………………………………………………...................................................................................................................................................................

Tempat Praktek : …………………………………………………...............................................................................................................................................................

Tanggal Pengkajian : ………………………………………………………………………………………......................................................................................................

Tanggal Praktek :............................................................................................................................................................................................................................................

I. IDENTITAS DATA.

Nama Klien : …………………………………………………………..........................................................................................................................

No. Rekam Medis : …………………………………………….............................................................................................................................................

Tempat/tgl lahir : ………………………………………………..........................................................................................................................……….....

Jenis Kelamin : …………………………………………………………….......................................................................................................................

Suku bangsa : …………………………………………………..…………......................................................................................................................

Bahasa yang dimengerti : ………………………………………………… ……….........................................................................................................................

Agama :………………………………………………...…………......................................................................................................................

Nama Ayah/Ibu/Wali : ………………………………………………...………….....................................................................................................................

Pekerjaan Ayah/Ibu/wali : ………………………………………………...………….....................................................................................................................

Pendidikan : …………………………………………………..…………......................................................................................................................

Alamat Ayah/ibu/wali : …………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………...

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

II. KELUHAN UTAMA……………………………………………………………………………………………………………………………………………………………………………………………………

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III. RIWAYAT KELUHAN SAAT INI……………………………………………………………………………………………………………………………………………………………………………………………………

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IV. RIWAYAT KESEHATAN MASA LALU


a. Prenatal : …………………………………………………………………………………………………………………………………………………………………………...

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b. Intra dan post natal : ………………………………………………………………………………………………………………………………………................

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c. Penyakit yang pernah diderita………………………………………………………………………………………………………………………………………………………………………………………………

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d. Hospitalisasi/tindakan operasi………………………………………………………………………………………………………………………………………………………………………………………………

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………………………………………………………………………………………………………………………………………………………………………………………………

e. Injury/kecelakaaan………………………………………………………………………………………………………………………………………………………………………………………………

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f. Alergi………………………………………………………………………………………………………………………………………………………………………………………………

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g. Imunisasi dan tes laboratorium


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h. Pengobatan………………………………………………………………………………………………………………………………………………………………………………………………

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V. RIWAYAT PERTUMBUHAN………………………………………………………………………………………………………………………………………………………………………………………………………

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………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………

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VI. PENGKAJIAN TINGKAT PERKEMBANGAN SAAT INI ( gunakan format

Denver/DDST )

a. Personal social…………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………

b.Adaptif Motorik halus…………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………

c. Bahasa…………………………………………………………………………………………………………………………………………………………………………………………

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d.Motorik kasar…………………………………………………………………………………………………………………………………………………………………………………………

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Inteprestasi…………………………………………………………………………………………………………………………………………………………………………………………………

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VII. RIWAYAT SOSIAL


a. Pengasuh………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

b. Hubungan dengan anggota keluarga………………………………………………………………………………………………………………………………………………………………………………………………

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c. Hubungan dengan teman sebaya………………………………………………………………………………………………………………………………………………………………………………………………

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d. Pembawaan secara umum………………………………………………………………………………………………………………………………………………………………………………………………

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VIII. RIWAYAT KELUARGA

a. Sosial Ekonomi………………………………………………………………………………………………………………………………………………………………………………………………

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b. Lingkungan rumah………………………………………………………………………………………………………………………………………………………………………………………………

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c. Penyakit keluarga………………………………………………………………………………………………………………………………………………………………………………………………

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d. Genogram

IX. POLA KESEHATAN


a. Pemeliharaan dan persepsi terhadap kesehatan………………………………………………………………………………………………………………………………………………………………………………………………

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b. Nutrisi (makanan an cairan)………………………………………………………………………………………………………………………………………………………………………………………………

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c. Aktivitas………………………………………………………………………………………………………………………………………………………………………………………………

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d. Tidur dan istirahat………………………………………………………………………………………………………………………………………………………………………………………………

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e. Eliminasi………………………………………………………………………………………………………………………………………………………………………………………………

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f. Pola hubungan………………………………………………………………………………………………………………………………………………………………………………………………

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g. Koping ………………………………………………………………………………………………………………………………………………………………………………………………

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h. Kognitif dan persepsi………………………………………………………………………………………………………………………………………………………………………………………………

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i. Seksual………………………………………………………………………………………………………………………………………………………………………………………………

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j. Nilai………………………………………………………………………………………………………………………………………………………………………………………………

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X. PEMERIKSAAN FISIK


a. Keadaan umum

Tingkat kesadaran : ……………………………………………….........................................................................................................................................

Nadi :..…………………….......... Suhu :.…………………….… RR :.. ……………………… TD : ………………………..........................

BB :...……………………… TB : ………………………... LLA : ………………………..... LK :……………………….......................

LP :..............................................

b. Kepala………………………………………………………………………………………………………………………………………………………………………………………………

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c. Dada………………………………………………………………………………………………………………………………………………………………………………………………

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d. Abdomen………………………………………………………………………………………………………………………………………………………………………………………………

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e. Genetalia………………………………………………………………………………………………………………………………………………………………………………………………

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f. Ektremitas………………………………………………………………………………………………………………………………………………………………………………………………

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g. Neurology………………………………………………………………………………………………………………………………………………………………………………………………

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XI. PEMERIKSAAN DIAGNOSTIK PENUNJANG……………………………………………………………………………………………………………………………………………………………………………………………………

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XII. INFORMASI LAIN


…………………………………………………………………………………………………………………………………………………………………………………………………

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XIII. ANALISA DATA


DATA MASALAH ETIOLOGI

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XIV. PRIORITAS MASALAH

1. ........................................................................................................................................................................................................................................................................................

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2. .……………………………………………………………………………………………………………………………………………………………………………….………..

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XV. RENCANA KEPERAWATAN

Nama Klien : ……………………………………………………………………………………….. Nama Mahasiswa :............................................................................................................................................................................

Ruang : ………………………………………………………………………………………... NIM :............................................................................................................................................................................

Diagnosa Medis : ………………………………………………………………………………………. Paraf :………………………………………………………………………………………........................................

NODIAGNOSA

KEPERAWATAN/MASALAH KOLABORATIF

TUJUAN DAN KRITERIA HASIL (NOC)

INTERVENSI(NIC)

RASIONAL

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NODIAGNOSA

KEPERAWATAN/MASALAH KOLABORATIF

TUJUAN DAN KRITERIA HASIL (NOC)

INTERVENSI(NIC)

RASIONAL

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XVI. CATATAN PERKEMBANGAN

DIAGNOSA KEPERAWATAN/MASALAH KOLABORATIF

Hari, Tanggal, & Jam IMPLEMENTASI EVALUASINama &

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DIAGNOSA KEPERAWATAN/MASALAH KOLABORATIF

Hari, Tanggal, & Jam IMPLEMENTASI EVALUASINama &

paraf.............................................................................

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