ASUHAN KEPERAWATAN PADA ……………

DENGAN GANGUAN SISTEM ……………………………………… : ……………………..………………….

DI RUANG …………………………………………………………………….
RS ………………………………………………………..

Nama : PELANGI SATIA NISA

NIM : 18210100071

PROGAM STUDI PROFESI NERS KEPERAWATAN

UNIVERSITAS INDONESIA MAJU (UIMA)

 FORMAT PENGKAJIAN KEPERAWATAN ANAK

I. Biodata

A. Identitas Klien
1. Nama/Nama panggilan : …………………………………………………………

2. Tempat tgl lahir/usia : …………………………………………………………

3. Jenis kelamin : …………………………………………………………

4. Agama : …………………………………………………………

5. Pendidikan : …………………………………………………………

6. Alamat : …………………………………………………………

7. Tgl masuk : .............................................. (jam ....................)

8. Tgl pengkajian : …………………………………………………………

9. Diagnosis medik : …………………………………………………………

B. Identitas Orang tua

1. Ayah

a. N a m a : …………………………………………………………

b. U s i a : …………………………………………………………

c. Pendidikan : …………………………………………………………

d. Pekerjaan : ………………………………………………………

e. A g a m a : …………………………………………………………

f. Alamat : …………………………………………………………
 2. Ibu

a. N a m a : ………………………………………………………

b. U s i a : …………………………………………………………

c. Pendidikan : …………………………………………………………

d. Pekerjaan : ……………………………………………………

e. Agama : …………………………………………………………

f. Alamat : …………………………………………………………

C. Identitas Saudara Kandung (Jika Ada)

No NAMA USIA HUBUNGAN STATUS KESEHATAN

II. Riwayat Kesehatan

A. RIWAYAT KESEHATAN SEKARANG

1. Keluhan utama : 
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 2. Riwayat penyakit sekarang :
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B. RIWAYAT KEHAMILAN DAN KELAHIRAN

1. Prenatal care
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2. Natal care
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3. Post natal
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C. RIWAYAT KESEHATAN YANG LALU

1. Riwayat Penyakit dahulu 
a. Pernah Dirawat :
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b. Pernah Di Operasi :
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c. Masih dalam Pengobatan:

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d. Kecelakaan :
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e. Riwayat Alergi :
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2. Riwayat Penyakit Keluarga

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 3. Genogram

4. Riwayat Immunisasi (imunisasi lengkap)

Waktu Reaksi setelah
NO Jenis immunisasi Frekuensi Frekuensi
pemberian pemberian
1. BCG
2. DPT (I,II,III)
3. Polio (I,II,III,IV)
4. Campak
5. Hepatitis

D. RIWAYAT TUMBUH KEMBANG

I. Usia anak saat
 Berguling : …………… bulan
 Duduk : …………… bulan
 Merangkak: …………… bulan
  Berdiri : …………… tahun
 Berjalan : …………… tahun
 Senyum kepada orang lain pertama kali : …………… tahun
 Bicara pertama kali : …………… tahun dengan menyebutkan : ……………
 Berpakaian tanpa bantuan : ………… tahun

II. Riwayat Nutrisi

 Pemberian ASI :………………………………………………………….
 Pemberian susu formula :
- Alasan pemberian :
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- Jumlah pemberian :
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- Cara pemberian :
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 Pola perubahan nutrisi tiap tahap usia sampai nutrisi saat ini
Usia Jenis Nutrisi Lama Pemberian
III. Riwayat Psikososial
1. Anak tinggal bersama : ................................................
2. Hubungan antar anggota keluarga : ................................................
3. Lingkungan Rumah : ................................................
4. Pengasuh anak : ................................................

IV. Riwayat Spiritual

1. Support sistem dalam keluarga : ................................................

2. Kegiatan keagamaan : ................................................

V. Reaksi Hospitalisasi
A. Pengalaman keluarga tentang sakit dan rawat inap
 Ibu membawa anaknya ke RS
karena : ...................................................................................
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 Apakah dokter menceritakan tentang kondisi
anak : ......................................................................................
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 Perasaan orang tua saat
ini : ........................................................................................
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 Orang tua selalu berkunjung ke
RS : .........................................................................................
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 Yang akan tinggal dengan
anak : ...............................................................................................
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B. Pemahaman anak tentang sakit dan rawat inap
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VI. PENGKAJIAN FISIK
a. Sistem Pernapasan
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b. Sistem Kardiovaskuler
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c. Sistem Persyarafan
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d. Sistem Perkemihan
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e. Sistem Pencernaan
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f. Sistem Muskuloskeletal
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g. Sistim Endokrin
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h. Sistim sensori persepsi/Pengideraan

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j. Sistim imun dan hematologi

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k. Sistem Reproduksi
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VII. PENGKAJIAN FUNGSIONAL

1. Oksigenisasi
Kondisi Sebelum Sakit Saat Sakit

2. Nutrisi
Kondisi Sebelum Sakit Saat Sakit

3. Cairan dan Elektrolit

Kondisi Sebelum Sakit Saat Sakit

 4. Eliminasi (BAB&BAK)
Kondisi Sebelum Sakit Saat Sakit

5. Istirahat dan Tidur

Kondisi Sebelum Sakit Saat Sakit

6. Personal Hygiene
Kondisi Sebelum Sakit Saat Sakit
 7. Aktifitas/Mobilitas Fisik
Kondisi Sebelum Sakit Saat Sakit
 VIII. PEMERIKSAAN PENUNJANG
a. Hasil Laboratorium
Tanggal Pemeriksaan Hasil Nilai Normal Interpretasi
b. Pemeriksaan Diagnostik
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c. Progam Terapi
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 ANALISIS DATA

Nama Klien : ____________________

Ruang : ____________________

TGL/JAM DATA ETIOLOGI MASALAH

PRIORITAS DIAGNOSIS KEPERAWATAN

Hari, tanggal : ___________________________

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