Professional Documents
Culture Documents
FORMAT ASKEP Anak 2018
FORMAT ASKEP Anak 2018
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Oleh :
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Mengetahui,
Kepala Ruangan
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PENGKAJIAN
Tanggal masuk : 13/01/2019 Pukul : ………....
Tanggal pengkajian : 14/01/2019 Pukul : ………....
No. Kamar : ………………………………………………………………
No. Register : ………………………………………………………………
Diagnosa medis : ………………………………………………………………
A. IDENTITAS
1. Nama Klien : ……………………………………………………
2. Tanggal Lahir : …………………………………………………...
3. Umur : ……………………………………………………
4. Jenis kelamin : ……………………………………………………
5. Anak ke- : ……………………………………………………
6. Pendidikan : ……………………………………………………
7. Agama : ……………………………………………………
8. Suku/bangsa : ……………………………………………………
9. Nama Ayah/Ibu : …………………………………………………....
10. Pendidikan Ayah/Ibu : ……………………………………………………
11. Pekerjaan Ayah/Ibu : ……………………………………………………
12. Alamat : ……………………………………………………
13. Penanggung jawab : ……………………………………………………
b. Natal :
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c. Post Natal :
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4. Penyakit-penyakit waktu kecil :
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5. Pernah di rawat di Rumah Sakit :
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6. Riwayat luka/operasi :
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7. Riwayat Alergi
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8. Tumbuh Kembang :
a. Motorik Kasar :
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b. Bahasa :
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c. Motorik Halus :
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d. Personal Sosial :
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9. Riwayat Imunisasi :
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2. Persepsi/Penatalaksanaan Kesehatan
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Keterangan skoring :
0 : mandiri
1 : dibantu sebagian
2 : perlu bantuan orang lain
3 : perlu bantuan orang lain dan alat
4 : tergantung/tidak mampu
5. Pola Eliminasi
a) BAB
Frekuensi : …………………………………………………….
Konsistensi : …………………………………………………….
Warna : …………………………………………………….
Keluhan : …………………………………………………….
Keterangan : …………………………………………………….
b) BAK
Frekuensi : …………………………………………………….
Warna : …………………………………………………….
Jumlah : …………………………………………………….
Keluhan : …………………………………………………….
Keterangan : …………………………………………………….
9. Pola Koping
a) Kehilangan perubahan yang terjadi sebelumnya :
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b) Koping adaptasi yang sering dipakai :
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D. PEMERIKSAAN FISIK
a. (Khusus Neonatus) :
1. Reflek Morro : ……………………………………………………
2. Reflek Rooting : ……………………………………………………
3. Reflek Menggenggam : ……………………………………………………
4. Reflek Sucking : ……………………………………………………
5. Tonus otot/aktivitas : ……………………………………………………
6. Kekuatan menangis : ……………………………………………………
7. Lain-lain : ……………………………………………………
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f. Mata :
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g. Telinga :
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h. Hidung :
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i. Mulut :
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j. Gigi :
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k. Lidah :
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l. Tenggorokan :
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m. Leher :
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n. Dada :
1. Paru paru :
Inspeksi
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Palpasi
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Perkusi
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Auskultasi
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2. Jantung
Inspeksi
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Palpasi
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Perkusi
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Auskultasi
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o. Abdomen :
Inspeksi
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Auskultasi
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Palpasi
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Perkusi
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p. Punggung :
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q. Genetalia :
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r. Extremitas :
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s. Integumen dan Kuku :
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E. PEMERIKSAAN PENUNJANG
Jenis Tanggal Hasil Pemeriksaan
Laboratoriu
m
Rx / Photo
USG
Jenis Tanggal Hasil Pemeriksaan
Lain-lain
F. TERAPI
Tanggal : ………………………………………
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Perawat
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ANALISA DATA
Nama : ……………………………..
No. register : ……………………………..
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Tanggal
Nama &
No. Diagnosa Keperawatan Ditemukan Teratas
Paraf
i
1
5
NURSING CARE PLAN (NCP)
Nama : ……………………………..
No. register : ……………………………..
No. Diagnosa Keperawatan Tujuan Kriteria Hasil Intervensi Rasional
IMPLEMENTASI dan EVALUASI
Nama : ……………………………..
No. register : ……………………………..
No.
Tgl/jam Implementasi Paraf Tgl/jam Evaluasi Paraf
Dx.Kep.