You are on page 1of 12

ILMU KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

FORMAT RESUME KASUS

1. IDENTITAS PASIEN
Inisial Pasien :........................................
Usia :........................................
Jenis Kelamin :........................................
Diagnosa Medis :........................................
Tanggal Pengkajian :........................................
Nama Ayah / Ibu :........................................
Pekerjaan Ayah/Ibu :........................................
Pendidikan Ayah/Ibu :........................................
Alamat :........................................

2. RIWAYAT PENYAKIT SEKARANG


a. Keluhan Utama
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

b. Penanganan yang telah dilakukan dan hasilnya


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

3. RIWAYAT KESEHATAN
a. Penyakit yang pernah diderita
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
b. Riwayat dirawat di RS
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
c. Riwayat Konsumsi obat-obatan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

d. Riwayat Operasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
e. Riwayat Alergi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

4. PEMERIKSAAN FISIK
a. Keadaan Umum :..........................................................................................................
..........................................................................................................
..........................................................................................................
..........................................................................................................
b. TB/BB :..........................................................................................................
c. Lingkar Kepala :..........................................................................................................
d. Tnda vital
- TD :..........................................................................................................
- HR :..........................................................................................................
- RR :..........................................................................................................
- Suhu :..........................................................................................................

5. PEMERIKSAAN STATUS NUTRISI


a. Klinik :..................................................................................................................................
b. BB/U :..................................................................................................................................
c. TB/U :..................................................................................................................................
d. BB/TB :..................................................................................................................................
e. Simpulan:...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

6. PEMERIKSAAN TINGKAT PERKEMBANGAN (DENVER II TEST)


a. Kemandirian dalam bergaul
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
b. Motorik halus
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

c. Motorik kasar
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
d. Kognitif dan bahasa
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

Simpulan Pemeriksaan Tingkat Perkembangan


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

7. RIWAYAT IMUNISASI
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

8. TERAPI OBAT-OBATAN ATAU TERAPI LAINNYA YANG SEDANG DIJALANI


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

9. RUMUSAN MASALAH

Analisa Data Masalah Keperawatan yang


Data
(Pohon Masalah) muncul (NANDA)
Data Analisa Data Masalah Keperawatan yang
(Pohon Masalah) muncul (NANDA)
Analisa Data Masalah Keperawatan yang
Data
(Pohon Masalah) muncul (NANDA)
Analisa Data Masalah Keperawatan yang
Data
(Pohon Masalah) muncul (NANDA)
10. CATATAN PERKEMBANGAN

No Diagnosa Keperawatan Implementasi Keperawatan Evaluasi (SOAP)


No Diagnosa Keperawatan Implementasi Keperawatan Evaluasi (SOAP)
No Diagnosa Keperawatan Implementasi Keperawatan Evaluasi (SOAP)
No Diagnosa Keperawatan Implementasi Evaluasi (SOAP)