INSTITUT TEKNOLOGI KESEHATAN DAN SAINS WIYATA HUSADA

SAMARINDA
FORMAT PENGKAJIAN ANAK

Nama Mahasiswa : ………………………………………………..

Tempat Praktek : ………………………………………………..
Tanggal Praktek : ………………………………………………..

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

B. Keluhan Utama
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C. Riwayat Keluhan Saat ini

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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. Penyakit waktu kecil
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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. Hubungan dengan anggota keluarga : ……………………………………………….
3. Hubungan dengan teman sebaya : …………………………………………………..

H. Riwayat Keluarga
1. Sosial ekonomi
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2. Lingkungan rumah
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3. Penyakit keluarga
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 4. Genogram
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I. Pengkajian Tingkat perkembangan saat ini

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J. Pengkajian Pola Kesehatan Saat ini

1. Pemeliharaan dan persepsi terhadap kesehatan
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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. Koping atau temperamen dan disiplin yang di terapkan

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9. Kognitif dan persepsi
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10. Konsep diri
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11. Seksual dan menstruasi
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12. Nilai
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K. Pemeriksaan Fisik
1. Keadaan umum
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§ Tanda-tanda vital :
o
TD: mm/H P: x/m N: x/m S: C
BB/TB :
§ Skala Nyeri :

§ Resiko Jatuh :
Skala Humpty Dumpty
Parameter Kriteria Nilai Skor
< 3 tahun
Usia 3-7 tahun
7-13 tahun
≥ 13 tahun
Jenis Kelamin Laki-Laki
Perempuan
Diagnosis Diagnosis neurologi
Perubahan oksigenasi (diagnosis respiratorik, dehidrasi, anemia, sinkop,
pusing)
Gangguan Perilaku/Psikiatri
Diagnosis lainnya
Gangguan Kognitif Tidak menyadari keterbatasan dirinya
Lupa akan adanya keterbatasan
Orientasi baik terhadap diri sendiri
Faktor lingkungan Riwayat jatuh/bayi diletakkan ditempat tidur dewasa
Menggunakan alat bantu/diletakkan dalam tempat tidur bayi
Pasien diletakkan di tempat tidur
Area di luar rumah sakit
Pembedahan/sedasi/ Dalam 24 jam
anastesi Dalam 48 jam
>48 jam atau tidak menjalani pembedahan/sedasi/anastesi
Penggunaan medika Penggunaan multiple : sedative, obat hypnosis, barbiturate, fenotiazin,
mentosa antidepresan, pencahar, diuretic, narkose
Penggunaan salah satu obat diatas
Penggunaan medikasi lainnya/tidak ada medikasi
Jumlah skor humpty dumpty
§ Skor 7-11 : resiko rendah
§ Skor ≥ 12 : resiko tinggi
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. Pemeriksaan Diagnostik lainnya

a. Pemeriksaan Laboratorium
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b. Pemeriksaan Rontgen
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c. Dan lain-lain
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M. Informasi lainnya (Program terapi dan Cairan

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

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 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)
/MASALAH KOLABORASI

Dst
 Catatan Perkembangan

Nama Klien : Umur :

No RM : Ruang :

Hari/Tgl No. Dx Implementasi Evaluasi Paraf

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