Professional Documents
Culture Documents
F.ANAKb Edit Baru
F.ANAKb Edit Baru
FORMAT PENGKAJIAN
( KEPERAWATAN ANAK )
A. PENGKAJIAN
1. Biodata
a. Nama : ……………………………………………….
b. Umur : ……………………………………………….
c. Jenis Kelamin : ……………………………………………….
d. Agama : ……………………………………………….
e. Suku/ Bangsa : ……………………………………………….
f. Alamat : ……………………………………………….
g. Pekerjaan : ……………………………………………….
h. Nomor Register : ……………………………………………….
i. Tanggal MRS : ……………………………………………….
j. Tanggal Pengkajian : ……………………………………………….
k. Diagnosa Medis : ……………………………………………….
Biodata Penanggungjawab
a. Nama : ……………………………………………….
b. Umur : ……………………………………………….
c. Jenis Kelamin : ……………………………………………….
d. Agama : ……………………………………………….
e. Pekerjaan : ……………………………………………….
f. Pendidikan : ………………………………………………
g. Status Perkawinan: ……………………………………………….
h. Suku Bangsa : ……………………………………………….
i. Alamat : ……………………………………………….
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7. Riwayat Perkembangan
a. Motorik Halus
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b. Motorik Kasar
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c. Bahasa / Komunikasi
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d. Adaptasi Sosial
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b. Pola Eliminasi
1). Buang Air Besar
a). Sebelum Sakit
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2). Hidung
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3). Telinga
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4). Mata
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(2). Palpasi
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(3). Perkusi
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(4). Auskultasi
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(2). Palpasi
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(3). Perkusi
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(4). Auskultasi
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8). Payudara
(a). Inspeksi
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(b). Palpasi
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(b). Auskultasi
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(c). Palpasi
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(d). Perkusi
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14. Penatalaksanaan
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15. Harapan Klien/ Keluarga sehubungan dengan Penyakitnya
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16. Genogram
ANALISA DATA
Nama Pasien :
No. Register :
Nama Pasien :
No. Register :
Nama Pasien :
No. Register :
TG NO TUJUAN KRITERIA HASIL INTERVENSI RASIONAL TT
L
19
CATATAN KEPERAWATAN
Nama Pasien :
No. Register :
NO T
TANGGAL JAM TINDAKAN KEPERAWATAN
DX T
CATATAN PERKEMBANGAN
Nama Pasien :
No. Register :
20
NO
TANGGAL TANGGAL TANGGAL
DX