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DEPARTEMEN KESEHATAN RI

POLITEKNIK KESEHATAN MALANG


PROGRAM STUDI KEPERAWATAN MALANG

FORMAT PENGKAJIAN PADA ANAK


A. PENGKAJIAN
1. PENGUMPULAN DATA
Tanggal

________________________
I.

II.

Identitas Data
Nama

_____________________

Alamat

: __________________

Tanggal Lahir

_____________________

No. Telp

: __________________

Umur : _____________

Kultur

: __________________

Nama Ayah/Ibu

_____________________

Agama

: __________________

Pekerjaan Ayah

_____________________

Pendidikan

: __________________

Pekerjaan Ibu

_____________________

Anak Ke

Alasan Kunjungan / Keluhan Utama :


______________________________________________________________________
______________________________________________________________________
__________

III.

Riwayat Penyakit Sekarang


______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_________________________

IV.

Riwayat Kehamilan dan Kelahiran.


a. Prenatal

_____________________________________________________________
________________________________________________________
_____
b. Natal

_____________________________________________________________
________________________________________________________
_____
c. Postnatal :
_____________________________________________________________
________________________________________________________
_____

V.

Riwayat Masa Lampau.


a. Penyakit-penyakit

waktu

kecil

________________________________________________
b. Pernah

dirawat

di

rumah

sakit

_______________________________________________
c. Obat-obatan
_____________________________________________________________
d. Tindakan

(misalnya

operasi)

________________________________________________
e. Allergi
__________________________________________________________________
f.

Kecelakaan
_____________________________________________________________

g. Imunisasi
_______________________________________________________________
VI.

Riwayat Keluarga
______________________________________________________________________
______________________________________________________________________

______________________________________________________________________
_______________

VII.

Riwayat Sosial
a. Yang

mengasuh

_________________________________________________________
b. Hubungan

dengan

anggota

keluarga

_________________________________________
c. Hubungan

dengan

teman

sebaya

____________________________________________
d. Pembawaan

secara

umum

_________________________________________________
e. Lingkungan

rumah

________________________________________________________

VIII.

Kebutuhan Dasar
a. Cairan
__________________________________________________________________
b. Makanan
________________________________________________________________
c. Pola

tidur

_______________________________________________________________
d. Mandi
__________________________________________________________________
e. Aktifitas

bermain

________________________________________________________
f.

Eliminasi
_______________________________________________________________

IX.

Keadaan Kesehatan saat ini.


a. Diagnosa
__________________________________________________________

medis

b. Tindakan

operasi

_________________________________________________________
c. Status

nutrisi

____________________________________________________________
d. Status

cairan

____________________________________________________________
e. Obat-obatan
_____________________________________________________________
f.

Aktifitas
________________________________________________________________

g. Tindakan

keperawatan

____________________________________________________
h. X

ray

_________________________________________________________________
i.

Lain-lain
________________________________________________________________

X.

Pemeriksaan fisik
a. Keadaan

Umum

________________________________________________________
b. Tanda Vital

_______________________________________________________
c. Pemeriksaan kepala leher :
___________________________________________________________________
___________________________________________________________________
__________
___________________________________________________________________
___________________________________________________________________
__________
d. Pemeriksaan integumen :

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
_______________
___________________________________________________________________
_____
e. Dada dan thorax :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
____________________
Payudara :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
____________________
Abdomen :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
____________________
Genetalia :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
____________________

Ekstrimitas :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
____________________

XI.

Pemeriksaan tingkat perkembangan


a. Motor

kasar

_____________________________________________________________
b. Motor

halus

_____________________________________________________________
c. Adaptasi

Sosial

__________________________________________________________
d. Bahasa
_________________________________________________________________

XII.

Informasi lain
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_______________

Malang,

( _______________________ )