Format Pengkajian Kep Anak Sehat [PDF]

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Format Pengkajian Keperawatan Anak UNSRAT



Program studi Ilmu Keperawatan FK–



FORMAT PENGKAJIAN ANAK SEHAT I. Identitas Anak A. Identitas Klien 1. Nama 2. Alamat 3. Nomor Telepon 4. Usia dan Tanggal Lahir 5. Tempat Lahir 6 Suku 7. Jenis Kelamin 8. Agama 9. Tanggal Wawancara 10. Pemberi Infomasi



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II. Pengkajian Fisik A. Pengukuran Pertumbuhan 1. Tinggi/Panjang Badan 2. Berat Badan 3. Lingkar Kepala 4. Lingkar Dada 5. Ketebalan Lemak dibawah kulit 6 Lingkar Lengan Atas 7. Tumbuh dan Tanggal Gigi



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................................................................... ................................................................... ................................................................... ................................................................... ................................................................... ................................................................... Tumbuh mulai ......................................... Tanggal mulai ...........................................



B. Pengukuran Fisiologis 1. Suhu 2. Nadi 3. Pernafasan 4. Tekanan Darah



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.......... °C .......... x/menit .......... x/menit .......... mmHg



C. Penampilan Umum



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D. Keadaaan Sistem 1. Pernafasan 2. Kardiovaskuler 3. Pencernaan 4. Persyarafan 5. Integumen 6 Muskuloskeletal 7. Endokrin 8. Reproduksi 9. Indera 10. Immunitas



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



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Format Pengkajian Keperawatan Anak UNSRAT



Program studi Ilmu Keperawatan FK–



III. Pengkajian Keluarga A. Komposisi Keluarga 1. Anggota dekat dari keluarga Nama : ................................................................................................... Umur : .................................................................................................. Hubungan : ................................................................................................... 2. Anggota Keluarga besar yang signifikant (Buat pohon keluarga dengan simbol kedekatan)



Dekat



Sangat Dekat



Jauh



Konflik



Dekat dan Konflik



3. Pernikahan, perpisahan, kematian pasangan atau perceraian yang terjadi sebelumnya. ........................................................................................................................................ B. Lingkungan rumah dan komunitas 1. Tipe tempat tinggal : ..................................................................................................... Jumlah ruangan : ...................................................................................................... Jumlah lantai : ..................................................................................................... Penghuni :..................................................................................................... 2. Peralatan yang ada di rumah (Keadekuatan alat rumah tangga) ........................................................................................................................... ............. 3. Gambaran keamanan (Tangga darurat, detector asap, terali pada jendela, penggunaan restrain mobil untuk anak) .............................................................................................................................. ........................................................................................................................................ .......... 4. Bahaya Lingkungan. ................................................................................................................... ........................................................................................................................................ ..................... 5. Ketersediaan lokasi dan fasilitas kesehatan, sekolah dan area bermain .......................................................................................................................... ........................................................................................................................................ .............. 6. Hubungan dengan tetangga ......................................................................................................................... ............... 7. Krisis atau perubahan terakhir dalam rumah ............................................................................................................................. ........... 8. Reaksi dan penyesuaian anak terhadap stress baru ............................................................................................................................... ......... C. Pekerjaan dan Pendidikan 2



Format Pengkajian Keperawatan Anak UNSRAT



Program studi Ilmu Keperawatan FK–



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Jenis Pekerjaan .............................................................................................................. 2. Jadwal kerja ................................................................................................................... 3. Kepuasaan kerja ............................................................................................................ 4. Terpapar bahaya lingkungan ......................................................................................... 5. Sumber pendapatan keluarga ......................................................................................... 6. Efek penyakit pada status financial ............................................................................... ........................................................................................................................................ D. Tradisi budaya dan agama 1. Keyakinan Realigius dan prakteknya ............................................................................ ........................................................................................................................................ 2. Keyakinan budaya etnis dan prakteknya ....................................................................... 3. Bahasa dirumah ............................................................................................................. E. Interaksi dan Peran keluarga, Pemecahan Masalah 1. Respon keluarga dengan yang lain (ramah, bermusuhan, dingin, mencintai, sabar & lekas marah) ............................................................................................................................ ........................................................................................................................................ ............ 2. Peran Kepemimpinan vs Kepatuhan ...................................................................................................................... ........................................................................................................................................ .................. 3. Dukungan dan perhatian yang ditunjukkan pada semua keluarga ......................................................................................................................... ........................................................................................................................................ ............... 4. Bagaimana penerapan aturan dalam keluarga ......................................................................................................................... ........................................................................................................................................ ............... 5. Bagaimana pemecahan masalah dan pengambilan keputusan ....................................................................................................................... ................. F. Komunikasi 1. Seberapa sering anggota keluarga menunggu sampai orang lain selesai sebelum gilirannya bicara ............................................................................................................................. ........... 3



Format Pengkajian Keperawatan Anak UNSRAT



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Program studi Ilmu Keperawatan FK–



Apakah orang tua / saudara kandung yang lebih tua cenderung mengajari atau mengkhotbahi ................................................................................................................ ........................



IV. Pengkajian Nutrisi A. Riwayat Diet 1. Pola makan keluarga umumnya .................................................................................................................... ................. 2. Apakah anggota keluarga makan bersama atau waktunya terpisah ........................................................................................................................ ............. 3. Siapa keluarga yang berbelanja dan menyiapkan makanan ...................................................................................................................... ............... 4. Berapa uang yang diperlukan untuk berbelanja setiap minggunya .................................................................................................................. ................... 5. Bagaimana umumnya makanan yang disiapkan (digoreng, bakar, rebus, dll) ............................................................................................................................... ...... 6. Seberapa sering anggota keluarga makan diluar ........................................................................................................................... .......... 7. Apakah anak makan teratur .......................................................................................................................... ........... 8. Makanan dan Minuman yang disukai anak ............................................................................................................................. ........ B. Pola Makan Anak 1. Makan Pagi (jenis, jumlah dan selera makan anak) ........................................................................................................................... .......... 2. Makan Siang ........................................................................................................................... .......... 3. Makan Malam ......................................................................................................................... ............ 4. Makan Selingan ...................................................................................................................... ............... 5. Kebiasaan Jajan ............................................................................................................................ ......... V. Pengkajian Tidur 4



Format Pengkajian Keperawatan Anak UNSRAT



Program studi Ilmu Keperawatan FK–



A. Riwayat Tidur 24 Jam 1. Waktu dan regularitas tidur .............................................................................................................................. ........ 2. Ritual sebelum tidur .............................................................................................................................. ........ 3. Lingkungan tidur .............................................................................................................................. ........ 4. Terbangun dimalam hari ............................................................................................................................... ....... 5. Perilaku tidur .............................................................................................................................. ........ 6. Persepsi orang tua tentang kebiasaan tidur anak .............................................................................................................................. ........ B. Catatan Tidur dalam 1 minggu ........................................................................................................................................... ........................................................................................................................................... VI. Pengkajian Perkembangan Menggunakan ”TES DENVER II” ........................................................................................................................................... ........................................................................................................................................... VII. Perkembangan Bahasa dan Bicara ........................................................................................................................................... ........................................................................................................................................... VIII. Pengkajian Bermain ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... DATA



ETIOLOGI



MASALAH



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Format Pengkajian Keperawatan Anak UNSRAT



Program studi Ilmu Keperawatan FK–



ASUHAN KEPERAWATAN



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