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FORMAT PENGKAJIAN

KEPERAWATAN PEDIATRIK
Program Studi Ilmu Keperawatan
Fakultas Kedokteran Universitas Gadjah Mada
Nama Mahasiswa : Siti Muttmainatul I. A. S.Kep
NIM
: 09/282303/KU/13266
Waktu Praktik
:
s/d

Ruangan
Pembimbing
Paraf

A. IDENTITAS DIRI KLIEN


Nama
: _________________
Nama Panggilan : _________________
Nomor RM
: _________________
Tempat, tgl lahir : _________________
Umur
: _________________
Jenis Kelamin
: _________________
Suku Bangsa
: _________________
Orang Tua (Ayah/Ibu/Wali)
Nama
: _________________
Agama
: _________________
Pendidikan
: _________________

:
: 1.
2.
:

Bahasa
Diagnosa Medis
Tanggal Masuk
Tanggal Pengkajian
Jam Pengkajian
Sumber Informasi

RSUP dr Sardjito

: _____________________
: _____________________
: _____________________
: _____________________
: _____________________
: _____________________

Pekerjaan : ___________________________
Alamat
: ___________________________
_____________________________________

B. RIWAYAT PENYAKIT
Keluhan Utama
:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Riwayat Keluhan Saat Ini
:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Riwayat Kesehatan Masa Lalu
:
a. Prenatal
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
b. Perinatal dan Post natal
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

c. Penyakit yang pernah di derita


__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
d. Hospitalisasi/tindakan operasi
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
e. Injury/kecelakaan
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
f. Alergi
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
g. Imunisasi dan test laboratorium
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
h. Pengobatan
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
C. RIWAYAT PERTUMBUHAN
__________________________________________________________________________________
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__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
D. RIWAYAT SOSIAL
a. Yang mengasuh
b. Hubungan dengan anggota keluarga
c. Hubungan dengan teman sebaya
d. Pembawaan secara umum

: ___________________________________________
: ___________________________________________
: ___________________________________________
: ___________________________________________

E. RIWAYAT KELUARGA
a. Sosial ekonomi
: _________________________________________________________
__________________________________________________________________________
b. Lingkungan rumah : _________________________________________________________
__________________________________________________________________________
c. Penyakit keluarga : _________________________________________________________
__________________________________________________________________________

d. Genogram
: _________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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__________________________________________________________________________
F. PENGKAJIAN TINGKAT PERKEMBANGAN SAAT INI (Denver/DDST)
a. Personal sosial
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
b. Adaptif motorik halus
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
c. Bahasa
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
d. Motorik kasar
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
G. PENGKAJIAN POLA KESEHATAN KLIEN SAAT INI
1. Pemeliharaan dan persepsi terhadap Kesehatan
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. Nutrisi dan Metabolic
Program diit RS : ___________________________________________________________
Intake makanan : ____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Intake Cairan : _____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

3. Pola Eliminasi
a. Buang air kecil : _________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
b. Buang air besar : ________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
4. Pola Aktivitas dan Latihan
Kemampuan Perawatan Diri
Makan dan Minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM

0 1 2 3 4

0 : Mandiri ; 1 : di bantu alat ; 2 : dibantu orang lain ; 3 : dibantu orang lain dan alat ; 4 : tergantung
total
Aktivitas :
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Oksigenasi :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
5. Pola Tidur dan Istirahat
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
6. Pola Persepsi, Sensori, dan Kognitif
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

7. Pola Persepsi Diri / Konsep Diri


__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
8. Pola Seksual dan Menstruasi
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
9. Pola Peran dan Hubungan
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
10. Pola Koping atau temperamen dan disiplin yang diterapkan
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
11. Sistem Keamanan dan Keyakinan Nilai
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Riwayat Pertumbuhan dan Perkembangan :_______________________________________
H. PEMERIKSAAN FISIK
Pemeriksaan Fisik (Chepalocaudal)
1. Keadaan Umum : ______________________ Tingkat kesadaran : ____________________
o
TD :
/
mmHg
; RR :
x/menit
; N :
x/menit
; S :
C
BB :
Kg
; TB :
cm
; LLA :
cm
; LK :
cm
2. Keluhan saat ini : _____________________________________________________________
_____________________________________________________________
_____________________________________________________________

3. Kulit
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

: _____________________________________________________________
_____________________________________________________________
Kepala
: _____________________________________________________________
_____________________________________________________________
Mata
: _____________________________________________________________
_____________________________________________________________
Telinga
: _____________________________________________________________
_____________________________________________________________
Hidung
: _____________________________________________________________
_____________________________________________________________
Mulut
: _____________________________________________________________
_____________________________________________________________
Leher
: _____________________________________________________________
_____________________________________________________________
Dada
: _____________________________________________________________
_____________________________________________________________
Payudara
: _____________________________________________________________
_____________________________________________________________
Paru-Paru
: _____________________________________________________________
_____________________________________________________________
Jantung
: _____________________________________________________________
_____________________________________________________________
Abdomen
: _____________________________________________________________
_____________________________________________________________
Genitalia
: _____________________________________________________________
_____________________________________________________________
Anus dan rektum : _____________________________________________________________
_____________________________________________________________
Muskuloskeletal : _____________________________________________________________
_____________________________________________________________
Neurologi
: _____________________________________________________________
_____________________________________________________________

I. INFORMASI LAIN (mencakup rangkuman kesehatan klien dari gizi, fisioterapis, medis
dll)
__________________________________________________________________________________
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J. PEMERIKSAAN DIAGNOSTIK PENUNJANG


Pemeriksaan

Hasil
i

Nilai

Normal

Yogyakarta, .............................................

Siti Muttmainatul Islamiyah Alawaliyah S.Kep


NIM : 09/282303/KU/13266