FORMAT PENGKAJIAN ANAK

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS ILMU KESEHATAN UNIVERSITAS MUHAMMADIYAH MALANG
STASE : KEPERAWATAN ANAK

Nama mahasiswa : ………………………………………………… Tanggal Praktek : ……………………………………….

NIM : ………………………………………………… Paraf :
Ruang : …………………………………………………
Tanggal Pengkajian : ………………………………………………… ( …………………………………………)

I. IDENTITAS DATA.
- Nomer Rekam Medis : …………………………………………… Tanggal masuk RS : ………………………………………
- Nama Klien : ………………………………………………… …………
- Nama Panggilan : ………………………………………………… …………
- Tempat/tgl lahir : ………………………………………………… …………
- Umur : ………………………………………………… …………
- Jenis Kelamin : ………………………………………………… …………
- Suku : ………………………………………………… …………
- Bahasa yang dimengerti : ………………………………………………… ………..
- Orang tua / wali : ………………………………………………… …………
- Nama Ayah/Ibu/Wali : ………………………………………………… …………
- Pekerjaan Ayah/Ibu/wali : ………………………………………………… …………
- Pendidikan : ………………………………………………… …………
- Alamat ayah/ibu/wali : ………………………………………………………………………………………………………………………………………….
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II. KELUHAN UTAMA

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III. RIWAYAT KELUHAN SAAT INI

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IV. KEADAAN KESEHATAN SAAT INI :

a. Diagnosa medis :
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b. Tindakan/kebutuhan operasi saat ini (jika ada) :
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c. Tindakan pemberian nutrisi saat ini :
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d. Tindakan pemberian cairan saat ini :
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e. Tindakan pemberian Obat-obatan saat ini :
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f. Tindakan terhadap Aktifitas saat ini (cth ; terpasang strain? Dll) :
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g. Tindakan Keperawatan lain-lain yang dijalani :
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 h. Tindakan /kebutuhan Px. Radiologi yang dijalani saat ini :
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i. Lain-lain :
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V. RIWAYAT KESEHATAN MASA LALU
a. Riwayat Prenatal :
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b. Riwayat Peri natal dan post natal :

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c. Riwayat Penyakit yang pernah diderita

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d. Riwayat Hospitalisasi/tindakan operasi

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e. Riwayat Injury/kecelakaaan
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f. Riwayat Alergi
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g. Riwayat Imunisasi
No Jenis Imunisasi Usia frekwensi pemberian Reaksi pasca imunisasi
1. Hepatitis
2. Polio
3. BCG
4 Pentabio
5. Campak
6. Lain-lain (sebutkan)
h. Riwayat tes laboratorium dan Pengobatan
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i. Riwayat pertumbuhan
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j. Riwayat perkembangan Psikososial

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k. Riwayat Perkembangan Psikoseksual

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l. Riwayat Perkembangan kognitif dan moral

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m. Riwayat pemenuhan nutrisi/cairan

- ASI
- MP ASI
- Pola nutrisi sesuai tahap usia
VI. RIWAYAT SOSIAL
a. Yang mengasuh
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b. Hubungan social dengan anggota keluarga

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c. Hubungan social dengan teman sebaya

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d. Pembawaan secara umum

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VII. RIWAYAT KELUARGA

a. Sosial Ekonomi
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b. Penyakit keluarga
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c. Genogram (Gambarkan minimal 3 generasi)

VIII. PENGKAJIAN TINGKAT PERKEMBANGAN (DDTK) SAAT INI ( maks < 6 tahun)
a. Personal social
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b.Adaptif Motorik halus

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c. Bahasa
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d.Motorik kasar
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Inteprestasi
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IX. PENGKAJIAN KEBUTUHAN DASAR (saat ini) :

a. Kebutuhan Cairan saat ini : Jelaskan dengan perhitungan intake output
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Interpretasi ______________________________________________________________
b. Kebutuhan Nutrisi saat ini :
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Interpretasi ______________________________________________________________
c. Kebutuhan Pola Tidur :
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d. Kebutuhan Personal hygiene (Mandi, gosok gigi dll):
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Interpretasi ______________________________________________________________
e. Kebutuhan Aktifitas / bermain :
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X. PENGKAJIAN POLA KESEHATAN (sesuai usia dan saat sakit saat ini)
a. Pola Pemeliharaan kesehatan dan persepsi terhadap kesehatan selama ini
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b. Pola pemenuhan Nutrisi selama ini

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c. Pola pemenuhan Cairan selama ini

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d. Pola Aktivitas selama ini

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e. Pola Tidur dan istirahat selama ini

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f. Pola Eliminasi selama ini

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g. Pola hubungan social selama ini

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h. Pola Koping atau temperamen dan disiplin yang diterapkan selama ini
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i. Pola perkembangan Kognitif dan persepsi selama ini

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j. Pola perkembangan Seksual dan menstruasi selama ini

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k. Pola perkembangan Moral (Nilai-nilai/values yang dimiliki selama ini)

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XI. PEMERIKSAAN FISIK

a. Keadaan umum
 Tingkat kesadaran : ………………………………………………
 Nadi : ……………………… Suhu : ……………………… RR : ……………………… TD : ………………………
 Respon nyeri : ……………………… ……………………… ………………………………………………………………………………………
 BB : ……………………… TB : ……………………… LLA : ……………………… LK : ………………………

b. Kulit
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c. Kepala
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d. Mata
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e. Telinga
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f. Hidung
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g. Mulut
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h. Leher
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i. Dada
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j. Payudara
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k. Paru-paru
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l. Jantung
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m. Abdomen
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n. Genetalia
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o. Punggung
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p. Anus dan rectum

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q. Musculoskeletal
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r. Neurology
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XII. PEMERIKSAAN DIAGNOSTIK PENUNJANG

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XIII. INFORMASI LAIN

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XIV. ANALISA DATA

No Data Penunjang Etiologi Masalah Keperawatan / Kolaboratif
1

dst

XV. PRIORITAS MASALAH

 1. .
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2. .
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3. .
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XVI. ASUHAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

 ASUHAN PERAWATAN
NAMA KLIEN : ………………………………………………………………………………………. NAMA MAHASISWA :
RUANG : ………………………………………………………………………………………. NIM :
DIAGNOSA MEDIS : ………………………………………………………………………………………. PARAF :……………………………………………………………………………………….
DIAGNOSA
TUJUAN DAN
NO KEPERAWATAN/MASAL INTERVENSI RASIONAL IMPLEMENTASI EVALUASI
KRITERIA HASIL
AH KOLABORATIF

CATATAN PERKEMBANGAN
NAMA KLIEN : ………………………………………………………………………………………. NAMA MAHASISWA :
RUANG : ………………………………………………………………………………………. NIM :
DIAGNOSA MEDIS : ………………………………………………………………………………………. PARAF :……………………………………………………………………………………….
DIAGNOSA KEPERAWATAN/MASALAH
NO CATATANPERKEMBANGAN
KOLABORATIF
1 …………………………..
S :….
O :…
A :…
P :…
I :…
E :…
R :…