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Oleh:
KEDIRI
2018
LEMBAR PENGESAHAN
LAPORAN PENDAHULUAN
Diajukan oleh
................................. .......................................
Mengetahui
Kepala Ruang Marwa
..................................................
LEMBAR PENGESAHAN
Diajukan oleh
………………………….. ……………………………..
Mengetahui ,
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I. BIODATA
A. Identitas Klien
1. Nama/Nama panggilan : ...............................................................................................
2. Tempat tanggal lahir / Usia : ...............................................................................................
3. Jenis Kelamin : ...............................................................................................
4. A g a m a : ...............................................................................................
5. Pendidikan : ...............................................................................................
6. A l a m a t : ...............................................................................................
7. Tanggal masuk : ...............................................................................................
8. Tanggal pengkajian : ...............................................................................................
9. Diagnosa Medik : ...............................................................................................
10. Rencana therapy : ...............................................................................................
B. Identitas Orang Tua
Ayah Ibu
Nama : .................................... Nama : ....................................
Usia : .................................... Usia : ....................................
Pendidikan : .................................... Pendidikan : ....................................
Pekerjaan/Penghasilan : .................................... Pekerjaan/Penghasilan : ....................................
Agama : .................................... Agama : ....................................
Alamat : .................................... Alamat : ....................................
C. Identitas Saudara Kandung
No Nama Usia Hubungan Ket
A. Dasar : B. Ulangan :
BCG : +/- Pada umur : Scar : X mm Pada Umur :
DPT : x Pada umur : Di : Pada Umur :
Polio : x Pada umur : Di : Pada Umur :
Campak : Pada Umur : Di :
5. Riwayat Penyakit Dahulu : (alergi, hospitalisasi, injury, pengobatan dll)
……………………………………………………………………………………………….............
……………………………………………………………………………………………….............
……………………………………………………………………………………………….............
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6. Riwayat Sosial, Ekonomi dan Lingkungan :
Yang Mengasuh…………………………………………………………………………….............
Pola Hubungan …………………………………………………………………………….............
……………………………………………………………………………………………….............
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7. Pemeriksaan Fisik Khusus :
a. Kesan Umum :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
b. Tanda Vital Utama :
Nadi : ........ x/menit, isi dan tegangan : ............... Teratur /tidak *)
Suhu : ........0C
Tekanan Darah : ........ mmHg
Pernafasan : ........ x/menit Tipe : ........................
c. Status Gizi :
Kesimpulan Status Gizi : Gizi lebih, Gizi baik, Gizi kurang, Gizi buruk *)
d. Kulit/integumen :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
e. Kelenjar limpe :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
f. Otot :
Pediatric Nursing Departement, 2016
www.ners.stikesstrada.ac.id
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
g. Tulang :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
h. Sendi :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
i. Jantung :
1) Batas Jantung (Jelaskan) : inspeksi, palpasi, perkusi
………………………………………………………………………………………..............
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2) Suara Jantung :
………………………………………………………………………………………..............
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j. Paru – paru/pernafasan (Inspeksi, Palpasi, Auskultasi, Perkusi):
Belakang
...............................................................................................................................................
...............................................................................................................................................
Pediatric Nursing Departement, 2016
www.ners.stikesstrada.ac.id
...............................................................................................................................................
...............................................................................................................................................
l. Anogenital :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
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m. Ekstremitas :
Refleks Pathologis
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...............................................................................................................................................
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o. Kepala :
1) Bentuk, rambut, kulit :
………………………………………………………………………………………..............
………………………………………………………………………………………..............
………………………………………………………………………………………..............
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2) Mata :
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3) Hidung :
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5) Mulut (dan Gigi):
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6) Pharynx, leher :
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Tanggal:
………………….,………………………….
Mahasiswa
(……………………………………..)
ANALISA DATA
Nama Pasien : Ruang :
Umur : Hari/tgl :
No Data Fokus Etiologi Problem/Masalah
RENCANA KEPERAWATAN
Nama Pasien : Ruang :
Umur : Hari/tgl :
Diagnosa Tujuan (NOC) Intervensi (NIC)
Sumber Informasi :
- Status/rekam medik pasien, Wawancara dengan orang tua, KMS anak
I. IDENTITAS ANAK
Pengkajian di lakukan tanggal .....................................
Nama Anak : ..............................................................................................
TTL : ..............................................................................................
Umur & jenis Kelamin : ..............................................................................................
Anak Ke : ..............................................................................................
II. IDENTITAS ORANG TUA
Ayah Ibu
Nama : ........................................... Nama : ...........................................
Usia : ........................................... Usia : ...........................................
Pendidikan : ........................................... Pendidikan : ...........................................
Pekerjaan : ........................................... Pekerjaan : ...........................................
Agama : ........................................... Agama : ...........................................
Suku : ........................................... Suku : ...........................................
Alamat : ........................................... Alamat : ...........................................
III. ANAMNESA
(1) Keluhan Utama :
............................................................................................................................... .........................
......................................................................................................
(2) Masalah tumbuh kembang :
............................................................................................................................... .........................
...................................................................................................... ..................................................
.............................................................................
IV. PENGKAJIAN PERTUMBUHAN DAN PERKEMBANGAN
(1) Pertumbuhan
Berat Badan ( BB ) : kg Status Gizi (BB/TB) : s/d SD
Tinggi Badan ( TB ) : cm Lingkar Kepala ( LK ): cm
Contoh Pada
(2) Perkembangan Usia 36 Bulan
1. KUESIONER PRA SKRINING PERKEMBANGAN ( KPSP )
KUISIONER PRA SKRINING PERKEMBANGAN USIA ....36...... BULAN
Tanggal Lahir :
5. Dapatkah anak melempar bola lurus ke arah perut atau dada anda dari jarak 1,5
meter?
6. Ikuti perintah ini dengan seksama. Jangan memberi isyarat dengan telunjuk atau
mata pada saat memberikan perintah berikut ini:
“Letakkan kertas ini di lantai”.
“Letakkan kertas ini di kursi”.
“Berikan kertas ini kepada ibu”.
Dapatkah anak melaksanakan ketiga perintah tadi?
7. Buat garis lurus ke bawah sepanjang sekurangkurangnya 2.5 cm. Suruh anak
menggambar garis lain di samping garis tsb.
8. Letakkan selembar kertas seukuran buku di lantai. Apakah anak dapat melompati
bagian lebar kertas dengan mengangkat kedua kakinya secara bersamaan tanpa
didahului lari?
9. Dapatkah anak mengenakan sepatunya sendiri?
10. Dapatkah anak mengayuh sepeda roda tiga sejauh sedikitnya 3 meter?
Interpretasi hasil yang di dapat dalam pemeriksaan KPSP dengan jumlah jawaban “Ya” yang dinilai
dengan point 10, perkembangan anak sesuai/tidak sesuai dengan tahap perkembangannya ( S )
Interpretasi Hasil :
Tidak ditemukan indikasi Gangguan Pemusatan Perhatian dan Hiperaktivitas (GPPH)
VI. INTERVENSI
No Hasil Pengkajian Intervensi
1. Pertumbuhan :
b. Lingkar Kepala : - .
Hasil ........................
2. Perkembangan :
a. Kuesioner Pra Skrining -
Perkembangan (KPSP)
untuk anak usia 36 bulan :
Interpretasi hasil
...................................
................................... .......
............................
b. Denver Developmental - Anjurkan orang tua ..................
Screening Test (DDST)
Interpretasi hasil :
...................................
c. TDD (Tes Daya Dengar) : - .
Hasil: ........................... ....
.................................
e. Kuesioner MME - .
f. CHAT (Checklist for
Autism in Toddlers)
g. Abbreviated Conners
Ratting Scala ( Conners )
VII. EVALUASI
Mahasiswa
(..................................................................)