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JURUSAN KEPERAWATAN MALANG

FORMAT PENGKAJIAN
ASUHAN KEPERAWATAN
PADA BAYI DAN ANAK

NAMA

NIM

KEMENTRIAN KESEHATAN
POLITEKNIK KESEHATAN MALANG
JURUSAN KEPERAWATAN MALANG

FORMAT PENGKAJIAN PADA ANAK


A. PENGKAJIAN
1. PENGUMPULAN DATA
Tanggal

Identitas Data
Nama
:
Tanggal Lahir
Umur :
Nama Ayah/Ibu

alamat
No.Telp
Kultur
Agama

:
:

Pekerjaan Ayah
:
:
Pekerjaan Ibu
:
Tanggal pengkajian
:

Pendidikan

Anak ke
:
penanggung jawab
Alamat

I.

II.

III.

:
:
:
:

Alasan Kunjungan / Keluhan Utama:


______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Riwayat Penyakit Sekarang:
_____________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Riwayat Kehamilan dan Kelahiran
a. Prenatal :
_____________________________________________________________
_____________________________________________________________
b. Natal
:
Pnjang badan
___________________________________________________________
___________________________________________________________
c. Postnatal:
Asi/tdk eksklusif/tdk. Brp lama?, makanan tmbahan
sejak kapan?
___________________________________________________________

IV.

___________________________________________________________
Riwayat masa lampau
a. Penyakit-penyakit waktu kecil
___________________________________________________________
___________________________________________________________
___________________________________________________________

V.

VI.

b. Pernah dirawat di Rumah sakit


___________________________________________________________
___________________________________________________________
c. Obat-obatan
Obat-obatan yg sering dikonsumsi, ex: ISPA (batuk,
pilek)tiap bulan Demam rheumatic,
___________________________________________________________
___________________________________________________________
d. Tindakan (missal : operasi)
___________________________________________________________
___________________________________________________________
e. Alergi
___________________________________________________________
___________________________________________________________
f. Kecelakaan
___________________________________________________________
___________________________________________________________
g. Imunisasi
1th= lengkap/tdk,
___________________________________________________________
___________________________________________________________
Riwayat Keluarga
Missal: typus, diare, (ada yang mengalami atau tdk?)
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Riwayat Sosial
a. Yang mengasuh
___________________________________________________________
___________________________________________________________
b. Hubungan dengan anggota keluarga
Anak dekat dg siapa?
___________________________________________________________
___________________________________________________________
c. Hubungan dengan teman sebaya

VII.

Tanya: anak baik,hebat mainnya sama siapa? Suak


main di luar rmah gak? (sebut teman), suka
berantem tdk?
___________________________________________________________
___________________________________________________________
d. Pembawaan secara umum
Lihat anak saat diajak komunikasi (perinag,
pendian, menutup diri dll)
___________________________________________________________
___________________________________________________________
e. Lingkungan rumah
Px tinggal didaerah kumuh, bersih dll
___________________________________________________________
___________________________________________________________
Kebutuhan Dasar
a. Cairan
Cairan selama 24 jam berapa? (untuk pertaman)
Ex: infuse berapa ml/24 jam, minum
Botol kecil 120 ml. besar 240 ml.
___________________________________________________________
___________________________________________________________
b. Makanan
Makan x/hari habis berapa porsi/ sendok
Kualitas: sayur, lauk, buah dll
___________________________________________________________
___________________________________________________________
c. Pola tidur
Kuntitas: sing, malam berapa? Kulitas: Sering
terbagun?
___________________________________________________________
___________________________________________________________
d. Mandi
Ex: Mandi 2x diseka bersih
___________________________________________________________
___________________________________________________________
e. Aktifitas/bermain
Sekarang sedang apa, klo diam/rewel beri
permainan (sesuai usia)
___________________________________________________________
___________________________________________________________
f. Eliminasi
___________________________________________________________
___________________________________________________________

VIII. Keadaan kesehatan saat ini


a. Diagnose medis
___________________________________________________________

___________________________________________________________
b. Tindakan
___________________________________________________________
___________________________________________________________
c. Status nutrisi
Akibat tubuh makan-makanan yang dimakan isi
(BB,LK,LL, TB)
___________________________________________________________
___________________________________________________________
d. Status cairan
Kelebihan (edema di derah..)
Kekurangan (tanda2 ddehidrasi)
___________________________________________________________
___________________________________________________________
e. Obat-obatan
___________________________________________________________
___________________________________________________________
f. Aktifitas
___________________________________________________________
___________________________________________________________

IX.

g. Tindakan keperawatan
Tindakan spesifik ex: typoiid = kompres, diet rebdah
serat
Ex: diare : rehidrasi per parenteral
___________________________________________________________
___________________________________________________________
h. X-ray
___________________________________________________________
___________________________________________________________
i. Lain-lain
___________________________________________________________
___________________________________________________________
Pemeriksaan Fisik
a. Keadaan umum:
___________________________________________________________
___________________________________________________________
b. Tanda vital:
___________________________________________________________
___________________________________________________________
c. Pemeriksaan kepala leher
___________________________________________________________
___________________________________________________________
d. Pemeriksaan integument
___________________________________________________________
___________________________________________________________
e. Dada dan thorax

___________________________________________________________
___________________________________________________________
f. Payudara
___________________________________________________________
___________________________________________________________
g. Abdomen
___________________________________________________________
___________________________________________________________
h. Genetalia
___________________________________________________________
___________________________________________________________
i. Ekstremitas
___________________________________________________________
___________________________________________________________
X.

Pemeriksaan tingkat perkembangan


a. Motor kasar :
___________________________________________________________
___________________________________________________________
b. Motor halus :
___________________________________________________________
___________________________________________________________
c. Adaptasi social :
___________________________________________________________
___________________________________________________________
d. Bahasa :
___________________________________________________________
___________________________________________________________

XI.

Informasi lain
______________________________________________________________
______________________________________________________________
______________________________________________________________

Malang, .................................
Perawat

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