FORMAT PENGKAJIAN ANAK

Nama Mahasiswa : ………………………………………………..

TempatPraktek : ………………………………………………..
TanggalPraktek : ………………………………………………..

I. Pengkajian
A. Identitas Data
1. Nama : ……………………………………………….
2. Tempat/Tgllahir : ……………………………………………….
3. Usia : ……………………………………………….
4. Nama Ayah/Ibu : ……………………………………………….
5. Pekerjaan Ayah : ……………………………………………….
6. Pekerjaanibu : ……………………………………………….
7. Pendidikan Ayah : ……………………………………………….
8. Pendidikan Ibu : ……………………………………………….
9. Agama : ……………………………………………….
10. Suku/Bangsa : ……………………………………………….
11. Alamat : ……………………………………………….

B. Keluhan Utama
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C. Riwayat KeluhanSaatini
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D. Riwayat Kesehatan Masa Lalu

 1. Prenatal
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2. Intranatal
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3. Postnatal
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E. Riwayat Masa Lalu

1. Penyakitwaktukecil
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2. Pernah di rawat di RS
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3. Obat-obatan yang digunakan
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4. Tindakan (operasi)
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5. Alergi
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6. Kecelakaan
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7. Imunisasi
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F. Riwayat Pertumbuhan dan perkembangan

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G. Riwayat Sosial
1. Yang mengasuh : ……………………………………………………………………
2. Hubungandengananggotakeluarga : ……………………………………………….
3. Hubungandengantemansebaya : …………………………………………………..

H. Riwayat Keluarga
1. Sosialekonomi
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2. Lingkunganrumah
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3. Penyakitkeluarga
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4. Genogram
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I. Pengkajian Tingkat perkembangansaatini

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J. Pengkajian Pola Kesehatan Saatini

1. Pemeliharaan dan persepsiterhadapkesehatan
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2. Nutrisi
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3. Cairan
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4. Aktivitas
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5. Tidur dan istirahat
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6. Eliminasi
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7. Pola hubungan
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8. Kopingatautemperamen dan disiplin yang di terapkan

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9. Kognitif dan persepsi
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10. Konsepdiri
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11. Seksual dan menstruasi
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12. Nilai
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K. PemeriksaanFisik
1. Keadaanumum
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 Tanda-tanda vital :
o
TD: mm/H P: x/m N: x/m S: C
BB/TB :
 Skala Nyeri :

 ResikoJatuh :
Skala Humpty Dumpty
Parameter Kriteria Nilai Skor
< 3 tahun
Usia 3-7 tahun
7-13 tahun
≥ 13 tahun
JenisKelamin Laki-Laki
Perempuan
Diagnosis Diagnosis neurologi
Perubahanoksigenasi (diagnosis respiratorik, dehidrasi, anemia, sinkop,
pusing)
GangguanPerilaku/Psikiatri
Diagnosis lainnya
GangguanKognitif Tidakmenyadariketerbatasandirinya
Lupaakanadanyaketerbatasan
Orientasibaikterhadapdirisendiri
Faktorlingkungan Riwayat jatuh/bayidiletakkanditempattidurdewasa
Menggunakanalat bantu/diletakkandalamtempattidurbayi
Pasiendiletakkan di tempattidur
Area di luarrumahsakit
Pembedahan/sedasi/ Dalam 24 jam
anastesi Dalam 48 jam
>48 jam atautidakmenjalanipembedahan/sedasi/anastesi
Penggunaanmedika Penggunaan multiple : sedative, obat hypnosis, barbiturate, fenotiazin,
mentosa antidepresan, pencahar, diuretic, narkose
Penggunaan salah satuobatdiatas
Penggunaanmedikasilainnya/tidakadamedikasi
Jumlahskorhumpty dumpty
 Skor 7-11 : resikorendah
 Skor ≥ 12 : resikotinggi
2. Kulit
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3. Kepala
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4. Mata
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5. Telinga
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6. Hidung
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7. Mulut
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8. Leher
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9. Dada
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10. Paru
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11. Jantung
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12. Abdomen
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13. Genetalia
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14. Anus dan rectum
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 15. Nuskuloskeletal
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16. Neurologi
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L. PemeriksaanDiagnostiklainnya
a. PemeriksaanLaboratorium
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b. Pemeriksaan Rontgen
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c. Dan lain-lain
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M. Informasilainnya (Program terapi dan Cairan

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Samarinda, ................... 20

Perawat

(...............................................)
 II. Analisa Data

No Data Penunjang Kemungkinan Penyebab Masalah

1. Data Subjektif :
dst

Data Objektif :

III. Diagnosa Keperawatan

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 RENCANA KEPERAWATAN

DIAGNOSA KEPERAWATAN
NO TUJUAN (NOC) INTERVENSI (NIC) RASIONAL
/MASALAH KOLABORASI

Dst
 Catatan Perkembangan

Nama Klien : Umur :

No RM : Ruang :

Hari/Tgl No. Dx Implementasi Evaluasi Paraf

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