FORMAT PENGKAJIAN ANAK DI RUMAH SAKIT

Nama mahasiswa

Dx

Tempat praktek/ujian :

MRS :

Tanggal pengkajian

BB

I. IDENTITAS
Nama (inisial)

TTL

Usia

Pendidikan

Alamat

Agama

Nama ayah/ibu

Pekerjaan ayah/ibu

Pendidikan ayah/ibu :
Agama

Alarnat
Suku/Bangsa

:
:

II. KELUHAN UTAMA

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KELUHAN TAMBAHAN
___________________________________________________________________________
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III. RIWAYAT PENYAKIT SEKARANG

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IV. RIWAYAT MASA LAMPAU
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__________________________________________________________________________
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V. RIWAYAT KELUARGA ( Disertai genogram )
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Keterangan:
: perempuan
: laki-laki

---------

: serumah

: klien
: garis
perkawinan
: garis
keturunan
: meninggal

VI. RIWAYAT SOSIAL

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VII. KEADAAN KESEHATAN SAAT INl

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VIII. PENGKAJIAN POLA FUNGSIONAL (MENURUT GORDON)

1. Persepsi kesehatan dan pola manajemen kesehatan
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2. Nutrisi- Pola Metabolik
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3. Pola eliminasi
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4. Aktivitas- Pola Latihan
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5. Pola Istirahat -Tidur

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6. Pola Kognitif -Persepsi
Anak:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Orang tua:
________________________________________________________________________
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7. Persepsi Diri - Pola Konsep Diri
Anak/bayi :
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
Orang tua:
________________________________________________________________________
_______________________________________________________________________
8. Pola Peran-Hubungan
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Orang tua:
________________________________________________________________________
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9. Sexualitas
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________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Orang tua:
________________________________________________________________________
_______________________________________________________________________
10. Koping -Pola Toleransi Stress
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________________________________________________________________________
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11. Nilai - Pola Keyakinan
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________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Orang tua:
________________________________________________________________________
_______________________________________________________________________
IX. PEMERIKSAAN FISIK

1.
2.
3.
4.

Keadaan umum: __________________________________________________________

Tanda vital: _____________________________________________________________
TB/BB ( persentil ): _______________________________________________________
Lingkar Kepala: __________________________________________________________

5. Mata: __________________________________________________________________
6. Hidung: ________________________________________________________________
7. Mulut: _________________________________________________________________
8. Telinga: ________________________________________________________________
9. Tengkuk: _______________________________________________________________
10. Dada: __________________________________________________________________
11. Jantung: ________________________________________________________________
12. Paru-paru: ______________________________________________________________
13. Perut: __________________________________________________________________
14. Punggung: ______________________________________________________________
15. Genitalia: _______________________________________________________________
16. Ekstrimitas: _____________________________________________________________
17. Kulit: __________________________________________________________________
X. PEMERIKSAAN PERKEMBANGAN
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DATA TAMBAHAN :
___________________________________________________________________________
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XI. HASIL PEMERIKSAAN LAB DAN PENUNJANG

No

Parameter

Hasil

Satuan

Nilai Normal

XII.

INFORMASI LAIN

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XIII. RINGKASAN RIWAYAT KEPERAWATAN
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XIV.

PATHWAYS KASUS

XV.

ANALISA DATA
DATA

MASALAH

ETIOLOGI

XVI.
PRIORITAS DIAGNOSA KEPERAWATAN
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XVII.
No.Dx

RENCANA KEPERAWATAN
Hari/tgl

Tujuan

Indicator

Intervensi

Awal

Tujuan

Rasional

No.Dx

Hari/tgl

Tujuan

Indicator

Intervensi

Awal

Tujuan

Rasional

XVIII.

IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Tgl/Jam No. Dx

Tindakan

Evaluasi (formatif)

Paraf

S:

O:

A:
Kriteria hasil

P:

Skala
awal

Skala
tujuan

Skala
dicapai

S:

O:

A:
Kriteria hasil

P:

Skala
awal

Skala
tujuan

Skala
dicapai

S:

O:

A:
Kriteria hasil

P:

Skala
awal

Skala
tujuan

Skala
dicapai

Tgl/Jam No. Dx

Tindakan

Evaluasi (formatif)

Paraf

S:

O:

A:
Kriteria hasil

P:

Skala
awal

Skala
tujuan

Skala
dicapai

XIX.

CATATAN PERKEMBANGAN

Catatan perkembangan dilakukan sebelum melanjutkan pengelolaan kasus pada hari berikutnya.
Fungsi catatan perkembangan adalah untuk mengetahui apakah masalah keperawatan klien
masih ada atau tidak.
Hari/
Tgl/Jam

Diagnosa keperawatan

Perkembangan (SOAP)