FORMAT PENGKAJIAN ASUHAN KEPERAWATAN ANAK

PROGRAM NERS B STIKES MUHAMMADIYA

BANJARMASIN

NAMA MAHASISWA
NPM
TEMPAT PRAKTIK
TANGGAL

: M. ABDY AGOES M, S.Kep

: 110153 B-S1
: ...........................................................
: ...........................................................

I. BIODATA KLIEN
A. Identitas Klien
1. Nama
2. Umur
3. Jenis kelamin
4. Agama
5. Pendidikan
6. Tanggal MRS
7. Alamat
8. Tanggal pengkajian
9. Diagnosa medik
B. Identitas Orang tua
1. Nama Ayah/Ibu
2. Pendidikan
3. Pekerjaan
4. A g a m a
5. Alamat
C. Identitas Saudara Kandung
No

Nama

:
:
:
:
:
:
:
:
:

PARAF CI

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Umur

Hubungan

Status kesehatan

II. RIWAYAT KESEHATAN

A. Riwayat Kesehatan Sekarang
1. Keluhan Utama
.............................................................................................................................................
2. Riwayat Keluhan Utama
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
3. Keluhan Pada Saat Pengkajian
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
B. Riwayat Kesehatan Lalu (khusus untuk anak usia 0 5 tahun)
1. Prenatal care
a. Ibu memeriksakan kehamilannya setiap minggu di........................................................

b. Keluhan selama hamil yang dirasakan oleh ibu, tapi oleh dokter dianjurkan untuk
.........................................................................................................................................
c. Riwayat terkena radiasi : ................................................................................................
d. Riwayat berat badan selama hamil : ..............................................................................
e. Riwayat Imunisasi TT :...................................................................................................
f. Golongan darah ibu .. Golongan darah ayah ..
2. Natal
a. Tempat melahirkan .........................................................................................................
b. Jenis persalinan ..............................................................................................................
c. Penolong persalinan .......................................................................................................
d. Komplikasi yang dialami oleh ibu pada saat melahirkan dan setelah melahirkan
.........................................................................................................................................
3. Post natal
a. Kondisi bayi : .APGAR .
b. Anak pada saat lahir tidak mengalami: ..........................................................................
c. Klien pernah mengalami penyakit : . pada umur : .
diberikan obat oleh : .......................................................................................................
d. Riwayat kecelakaan : .....................................................................................................
e. Riwayat mengkonsumsi obat-obatan berbahaya tanpa anjuran dokter dan
menggunakan zat/subtansi kimia yang berbahaya : .......................................................
f. Perkembangan anak dibanding saudara-saudaranya : ....................................................
C. Riwayat Kesehatan Keluarga
Genogram

Keterangan:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
III. RIWAYAT IMMUNISASI (IMUNISASI LENGKAP)
No
1.
2.
3.
4.
5.

Jenis Imunisasi

Waktu pemberian

Frekuensi

BCG
DPT (I,II,III)
Polio (I,II,III,IV)
Campak
Hepatitis

IV. RIWAYAT TUMBUH KEMBANG

A.
Pertumbuhan Fisik
1.
Berat badan : kg
2.
Tinggi badan :. cm.

Reaksi setelah
pemberian

Frekuensi

3.

Waktu tumbuh gigi . gigi tanggal Jumlah gigi

..............buah.
B.
Perkembangan Tiap tahap
Usia anak saat
1.
Berguling : bulan
2. Duduk
: bulan
3. Merangkak
: bulan
4. Berdiri
: tahun
5. Berjalan
: tahun
6. Senyum kepada orang lain pertama kali : tahun
7. Bicara pertama kali : tahun dengan menyebutkan : .....................................
8. Berpakaian tanpa bantuan : .................................................................................................
V. RIWAYAT NUTRISI
A. Pemberian ASI
..................................................................................................................................................
B. Pemberian susu formula
1. Alasan pemberian : ..........................................................................................................
2. Jumlah pemberian : ..........................................................................................................
3. Cara pemberian
: ..........................................................................................................
C. Pola perubahan nutrisi tiap tahap usia sampai nutrisi saat ini
Umur
Jenis Nutrisi
Lama Pemberian

VI. RIWAYAT PSIKOSOSIAL

A. Anak tinggal bersama : ................................................ di : ....................................................
B. Lingkungan berada di : ............................................................................................................
C. Rumah dekat dengan :................................................, tempat bermain ..................................
D. Hubungan antar anggota keluarga : .........................................................................................
E. Pengasuh anak : ......................................................................................................................
VII. RIWAYAT SPIRITUAL
A. Support sistem dalam keluarga : ..............................................................................................
B. Kegiatan keagamaan : .............................................................................................................
VIII. REAKSI HOSPITALISASI
A. Pengalaman keluarga tentang sakit dan rawat inap
1. Ibu membawa anaknya ke RS karena : ...............................................................................
2. Apakah dokter menceritakan tentang kondisi anak: ...........................................................
3. Perasaan orang tua saat ini : ..............................................................................................
4. Orang tua selalu berkunjung ke RS: ...................................................................................
B. Pemahaman anak tentang sakit dan rawat inap
.................................................................................................................................................
.................................................................................................................................................
IX. AKTIVITAS SEHARI-HARI
A. Nutrisi
Kondisi
Selera makan

Sebelum Sakit

Saat Sakit

B. Cairan
Kondisi
Jenis minuman
Frekuensi minum
Kebutuhan cairan
Cara pemenuhan

1.
2.
3.
4.

Sebelum Sakit

Saat Sakit

Sebelum Sakit

Saat Sakit

C. Eliminasi (BAB&BAK)
Kondisi
Tempat pembuangan
Frekuensi (waktu)
Konsistensi
Kesulitan
Obat pencahar

1.
2.
3.
4.
5.

D. Istirahat tidur
Kondisi
1. Jam tidur
Siang
Malam
2. Pola tidur
3.
Kebiasaan sebelum
tidur
4. Kesulitan tidur

Sebelum Sakit

Saat Sakit

Sebelum Sakit

Saat Sakit

Sebelum Sakit

Saat Sakit

E. Olah Raga
Kondisi
Program olah raga
Jenis dan frekuensi
Kondisi setelah olah

1.
2.
3.
raga

F.

Personal Hygiene
Kondisi
1. Mandi
- Cara
- Frekuensi
- Alat mandi
2. Cuci rambut
- Frekuensi
- Cara
3. Gunting kuku
- Frekuensi
- Cara
4. Gosok gigi
- Frekuensi
- Cara

G. Aktifitas/Mobilitas Fisik
1.
2.

Kondisi
Kegiatan sehari-hari
Pengaturan
jadwal
harian

Sebelum Sakit

Saat Sakit

3.

Penggunaan alat Bantu

aktifitas
4.
Kesulitan
pergerakan
tubuh

H. Rekreasi
1.
2.
3.
4.
5.

Kondisi
Perasaan saat
sekolah
Waktu luang
Perasaan setelah
rekreasi
Waktu senggang
klg
Kegiatan hari libur

Sebelum Sakit

Saat Sakit

X. PEMERIKSAAN FISIK
A. Keadaan umum
..................................................................................................................................................
B. Kesadaran
C. Tanda tanda vital :
1. Tekanan darah
: ..................................... mmHg
2. Denyut nadi
: ..................................... x / menit
3. Suhu
: ..................................... o C
4. Pernapasan
: ..................................... x/ menit
D. Berat Badan
:
Kg
E. Tinggi Badan
:
Cm
F. Kepala
1.
Inspeksi
a. Keadaan rambut & Hygiene kepala................................................................................
b. Warna rambut..................................................................................................................
c. Penyebaran......................................................................................................................
d. Mudah rontok..................................................................................................................
e. Kebersihan rambut..........................................................................................................
2. Palpasi
a. Benjolan
b. Nyeri tekan
c. Tekstur rambut (kasar/halus):
G.
Muka
1.
Inspeksi
a. Simetris / tidak
b. Bentuk wajah
c. Gerakan abnormal ..........................................................................................................
d. Ekspresi wajah
2.
Palpasi (nyeri tekan/tidak)
............................................................................................................................................
H.
Mata
1.
Inspeksi
a. Pelpebra (Edema, Radang) .............................................................................................
b. Sclera (Icterus/tidak) ......................................................................................................

c. Conjungtiva (Radang, Anemis) ......................................................................................

d. Pupil (Isokor/anisokor, Myosis/midriasis, Refleks pupil terhadap cahaya)....................
.........................................................................................................................................
e. Posisi mata (Simetris/ tidak)...........................................................................................
f. Gerakan bola mata .........................................................................................................
g. Penutupan kelopak mata ................................................................................................
h. Keadaan bulu mata ........................................................................................................
i. Keadaan visus ................................................................................................................
j. Penglihatan (kabur/tidak, diplopia/tidak) .......................................................................
2.
Palpasi (tekanan bola mata)
.............................................................................................................................................
I. Hidung & Sinus (posisi hidung, bentuk hidung, keadaan septum, secret/cairan)
..................................................................................................................................................
..................................................................................................................................................
J. Telinga
1.
Inspeksi
a. Posisi telinga
b. Ukuran/bentuk telinga
c. Aurikel
d. Lubang telinga (Bersih/serumen/nanah) ........................................................................
e. Pemakaian alat bantu
2.
Palpasi
a. Nyeri tekan/tidak
b. Pemeriksaan uji pendengaran (Rinne, Weber, Swabach)................................................
.........................................................................................................................................
c. Pemeriksaan vestibuler
K. Mulut
1.Gigi (Karang gigi/karies, pemakaian gigi palsu) ..................................................................
2.Gusi (Merah/radang/tidak) ...................................................................................................
3.Lidah (Kotor/tidak) ...............................................................................................................
4.Bibir (Cianosis, basah/kering/pecah) ...................................................................................
5.Mulut (berbau/tidak) .............................................................................................................
6.Kemampuan bicara ...............................................................................................................
7.Tenggorokan (warna mukosa, nyeri tekan, nyeri menelan) .................................................
.............................................................................................................................................
L.Leher (pembesaran kelenjar tiroid) ...........................................................................................
M.
Thorax dan pernapasan
1. Inspeksi
a. Bentuk dada ...................................................................................................................
b. Irama pernafasan ............................................................................................................
c. Pengembangan di waktu bernapas .................................................................................
d. Tipe pernapasan .............................................................................................................
2. Palpasi
a. Vokal fremitus
b. Massa/nyeri
3. Auskultasi
a. Suara nafas (vesikuler/bronchial/bronchovesikuler) ......................................................
b. Suara tambahan (ronchi / wheezing / rales) ...................................................................
4. Perkusi (Redup/pekak/hypersonor/tympani)
.............................................................................................................................................

N. Jantung
1. Palpasi (Ictus cordis)
2. Perkusi (pembesaran jantung)
3. Auskultasi
a. BJ I
b. BJ II
c. Bunyi jantung tambahan ................................................................................................
O. Abdomen
1. Inspeksi (asites, ada luka/tidak)
.............................................................................................................................................
2. Palpasi
a. Hepar
b. Lien
c. Nyeri tekan
3. Auskultasi (peristaltik)
4. Perkusi (Tympani, Redup)
P. Genitalia dan Anus ..................................................................................................................
Q. Ekstremitas
1. Ekstremitas atas
a. Motorik
- Pergerakan kanan/kiri ..................................................................................................
- Pergerakan abnormal ...................................................................................................
- Kekuatan otot kanan/kiri .............................................................................................
- Tonus otot kanan/kiri ...................................................................................................
- Koordinasi gerak ..........................................................................................................
b. Refleks
- Biceps kanan / kiri .......................................................................................................
......................................................................................................................................
- Triceps kanan / kiri ......................................................................................................
......................................................................................................................................
c. Sensori
- Nyeri
- Rangsang suhu
- Rasa raba
2. Ekstremitas bawah
a. Motorik
- Gaya berjalan
- Kekuatan kanan / kiri ...................................................................................................
b. Tonus otot kanan / kiri ..................................................................................................
c. Refleks (reflek patella) ...................................................................................................
d. Sensori
- Nyeri
- Rangsang suhu .............................................................................................................
- Rasa raba ......................................................................................................................

R. STATUS NEUROLOGI
1. Saraf cranial
a. Nervus I (Olfactorius) : penghidu ..................................................................................
b. Nervus II (Opticus) : Penglihatan ..................................................................................
c. Nervus III, IV, VI (Oculomotorius, Trochlearis, Abducens)
- Konstriksi pupil............................................................................................................
- Gerakan kelopak mata..................................................................................................
- Pergerakan bola mata....................................................................................................
- Pergerakan mata ke bawah & dalam............................................................................
d. Nervus V (Trigeminus)
- Sensibilitas / sensori ....................................................................................................
- Refleks dagu ................................................................................................................
- Refleks cornea .............................................................................................................
e. Nervus VII (Facialis)
- Gerakan mimik.............................................................................................................
- Pengecapan 2/3 lidah bagian depan .............................................................................
f. Nervus VIII (Acusticus) Fungsi pendengaran ...............................................................
.......................................................................................................................................
.......................................................................................................................................
g. Nervus IX dan X (Glosopharingeus dan Vagus)
- Refleks menelan ..........................................................................................................
- Refleks muntah ............................................................................................................
- Pengecapan 1/3 lidah bagian belakang ........................................................................
- Suara
h. Nervus XI (Assesorius)
- Memalingkan kepala ke kiri dan ke kanan .................................................................
- Mengangkat bahu ........................................................................................................
i. Nervus XII (Hypoglossus) Deviasi lidah .......................................................................
2. Tanda tanda perangsangan selaput otak
a. Kaku kuduk
b. Kernig Sign
c. Refleks Brudzinski..........................................................................................................
d. Refleks Lasegu
XI. PEMERIKSAAN TINGKAT PERKEMBANGAN (0 6 TAHUN )
Dengan menggunakan DDST
1. Motorik kasar ..........................................................................................................................
2. Motorik halus ..........................................................................................................................
3. Bahasa .....................................................................................................................................
4. Personal social .........................................................................................................................
XII. TEST DIAGNOSTIK
A. Laboratorium
................................................................................................................................................

................................................................................................................................................
................................................................................................................................................
B. Foto Rotgen, CT Scan, MRI, USG, EEG, ECG
................................................................................................................................................
................................................................................................................................................
XIII. TERAPI SAAT INI
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