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
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b. Penanganan yang telah dilakukan dan hasilnya

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3. RIWAYAT KESEHATAN
a. Penyakit yang pernah diderita
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b. Riwayat dirawat di RS
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c. Riwayat Konsumsi obat-obatan
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d. Riwayat Operasi
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 e. Riwayat Alergi
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4. PEMERIKSAAN FISIK
a. Keadaan Umum :..........................................................................................................
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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:...............................................................................................................................
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6. PEMERIKSAAN TINGKAT PERKEMBANGAN (DENVER II TEST)

a. Kemandirian dalam bergaul
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b. Motorik halus
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c. Motorik kasar
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d. Kognitif dan bahasa
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Simpulan Pemeriksaan Tingkat Perkembangan

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7. RIWAYAT IMUNISASI
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8. TERAPI OBAT-OBATAN ATAU TERAPI LAINNYA YANG SEDANG DIJALANI

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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)