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PROGRAM STUDI NERS STIKES YARSI PONTIANAK

ILMU KEPERAWATAN ANAK


FORMAT PENGKAJIAN ANAK

Nama Mahasiswa:
Tempat praktek :
Tanggal praktek :
DATA IDENTITAS
Nama
Tempat/tanggal lahir
Nama ayah/ibu
Pekerjaan Ayah
Pekerjaan Ibu

:................................
: ................................
: ................................
: ................................
: ................................

Alamat
: ................................
Agama
: ................................
Suku Bangsa : ................................
Pendidikan Ayah : ............................
Pendidikan Ibu : ................................

KELUHAN UTAMA
Riwayat kehamilan dan kelahiran:
Prenatal : ............................................................................................................................
...............................................................................................................................................
.................................................................................................................................
Intranatal : ............................................................................................................................
...............................................................................................................................................
.................................................................................................................................
Pasca natal
: ........................................................................................................................................
...............................................................................................................................................
....................................................................................................................
RIWAYAT KESEHATAN MASA LALU
Penyakit waktu kecil
: ........................................................................................................................................
...............................................................................................................................................
.....................................................................................................................
Dirawat di rumah
sakit: .....................................................................................................................................
...............................................................................................................................................
........................................................................................................................
Obat-obatan yang
digunakan : ...........................................................................................................................
...............................................................................................................................................
..................................................................................................................................

Tindakan
(operasi): ...............................................................................................................................
...............................................................................................................................................
..............................................................................................................................
Alergi
: ............................................................................................................................
...............................................................................................................................................
.................................................................................................................................
Kecelakaan : .........................................................................................................................
...............................................................................................................................................
....................................................................................................................................
Imunisasi : ............................................................................................................................
...............................................................................................................................................
.................................................................................................................................
RIWAYAT KELUARGA DISERTAI GENOGRAM

RIWAYAT SOSIAL
Yang
mengasuh: .............................................................................................................................
...........................................................................................................................................
Hubungan dengan anggota
keluarga : ..............................................................................................................................
...............................................................................................................................................
...............................................................................................................................
Hubungan dengan teman
sebaya : .................................................................................................................................
2

...............................................................................................................................................
............................................................................................................................
Pembawaan secara
umum : ..................................................................................................................................
...............................................................................................................................................
...........................................................................................................................
Lingkungan rumah (disertai dengan denah
rumah) : ................................................................................................................................
...............................................................................................................................................
.............................................................................................................................

KEBUTUHAN DASAR
Makanan yang
disukai : ................................................................................................................................
...............................................................................................................................................
.............................................................................................................................
Selera
makan: ..................................................................................................................................
......................................................................................................................................
Frekuensi : ............................................................................................................................
............................................................................................................................................
porsi
makan : .................................................................................................................................
...............................................................................................................................................
............................................................................................................................
pola
makan : .................................................................................................................................
...............................................................................................................................................
............................................................................................................................
Alat makan yang
digunakan : ...........................................................................................................................
.............................................................................................................................................
Pola
tidur : ....................................................................................................................................
....................................................................................................................................
Ritual/kebiasaan sebelum
tidur : ....................................................................................................................................
3

...............................................................................................................................................
.........................................................................................................................
Tidur
siang : ...................................................................................................................................
.....................................................................................................................................
Mandi : .................................................................................................................................
...............................................................................................................................................
............................................................................................................................
Aktivitas
bermain : ...............................................................................................................................
...............................................................................................................................................
..............................................................................................................................
Eliminasi : ............................................................................................................................
...............................................................................................................................................
.................................................................................................................................
KESEHATAN SAAT INI
Diagnosis
medis : ..................................................................................................................................
..
Tindakan
operasi : ................................................................................................................................
...............................................................................................................................................
.............................................................................................................................
Status
nutrisi : ..................................................................................................................................
...............................................................................................................................................
...........................................................................................................................
Status
cairan : ..................................................................................................................................
...............................................................................................................................................
..........................................................................................................................
Obatobatan : .................................................................................................................................
...............................................................................................................................................
............................................................................................................................
Aktivitas : .............................................................................................................................
...............................................................................................................................................
................................................................................................................................
Tindakan
Keperawatan : .......................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
..........................................................................................................................

Hasil
laboratorium : .......................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
.....................................................................................................
Hasil
roentgen : ..............................................................................................................................
...............................................................................................................................................
...............................................................................................................................
Data
tambahan : ............................................................................................................................
...............................................................................................................................................
.................................................................................................................................
PEMERIKSAAN FISIK
Keadaan
umum : ..................................................................................................................................
...............................................................................................................................................
...........................................................................................................................
TB / BB
(%) : ......................................................................................................................................
..................................................................................................................................
Lingkar kepala (anak usia < 2
tahun) : ..................................................................................................................................
......................................................................................................................................
Mata : ....................................................................................................................................
....................................................................................................................................
Hidung : ................................................................................................................................
........................................................................................................................................
Mulut : ..................................................................................................................................
......................................................................................................................................
Telinga : ................................................................................................................................
........................................................................................................................................
Tengkuk : ..............................................................................................................................
..........................................................................................................................................
Dada : ...................................................................................................................................
.....................................................................................................................................
Jantung : ...............................................................................................................................
.........................................................................................................................................
Paruparu : .....................................................................................................................................
...................................................................................................................................
Perut : ...................................................................................................................................
....................................................................................................................................
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Punggung: ............................................................................................................................
............................................................................................................................................
Genitalia : .............................................................................................................................
...........................................................................................................................................
Ekstremitas : .........................................................................................................................
...............................................................................................................................................
Kulit : ....................................................................................................................................
....................................................................................................................................
Tanda vital: Suhu:
Denyut Nadi:
Tekanan darah:

PEMERIKSAAN TINGKAT PERKEMBANGAN


Kemandirian dan
Bergaul : ...............................................................................................................................
...............................................................................................................................................
..............................................................................................................................
Motorik
Halus : ..................................................................................................................................
...............................................................................................................................................
...........................................................................................................................
Bernalar dan
Berbahasa : ...........................................................................................................................
...............................................................................................................................................
..................................................................................................................................
Motorik
Kasar : ..................................................................................................................................
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INFORMASI LAIN

RINGKASAN RIWAYAT KESEHATAN

ANALISIS DATA
DATA KLIEN
(SYMPTOM)

KEMUNGKINAN
PENYEBAB
(ETIOLOGI)

MASALAH
KEPERAWATAN
(PROBLEM)

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