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Published by: Delmi Thu Amie on May 26, 2010
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FORMAT PENGKAJIAN

RUANG PERAWATAN ANAK
I. Biodata
A. Identitas Klien
1. Nama/Nama panggilan : ……………………………………………………………………
2. Tempat tgl lahir/usia : ……………………………………………………………………
3. Jenis kelamin : ……………………………………………………………………
. A g a m a : ……………………………………………………………………
!. "endidikan : ……………………………………………………………………
#. Alamat : ……………………………………………………………………
$. Tgl masuk : ...................................... %&am ............'
(. Tgl pengka&ian : ……………………………………………………………………
). *iagnosa medik : ……………………………………………………………………
1+. ,en-ana terapi : ……………………………………………………………………
……………………………………………………………………
……………………………………………………………………
B. Identitas .rang tua
1. A/ah
a. N a m a : ……………………………………………………………………
0. 1 s i a : ……………………………………………………………………
-. "endidikan : ……………………………………………………………………
d. "eker&aan/sum0er penghasilan : ……………………………………………………………
e. A g a m a : ……………………………………………………………………
2. Alamat : ……………………………………………………………………
2. I0u
a. N a m a : ……………………………………………………………………
0. 1 s i a : ……………………………………………………………………
-. "endidikan : ……………………………………………………………………
d. "eker&aan/3um0er penghasilan: ……………………………………………………………
e. Agama : ……………………………………………………………………
2. Alamat : ……………………………………………………………………
NERS 04 STIKES NH MAKASSAR
4. Identitas 3audara Kandung
No N A M A U S I A HUBUNGAN STATUS KESEHATAN
II. ,i5a/at Kesehatan
A. ,i5a/at Kesehatan 3ekarang :
Keluhan 1tama : ……………………………………………………………………………..
,i5a/at Keluhan 1tama :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Keluhan "ada 3aat "engka&ian :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
B. ,i5a/at Kesehatan 6alu %khusus untuk anak usia + 7 ! tahun'
1. "renatal -are
a. I0u memeriksakan kehamilann/a setiap minggu di…………………….
Keluhan selama hamil /ang dirasakan oleh i0u8 tapi oleh dokter dian&urkan untuk
………………………………………………………………………………………………
0. ,i5a/at terkena radiasi : ……………………………………….
-. ,i5a/at 0erat 0adan selama hamil : …………………………………..
e. ,i5a/at Imunisasi TT : ………………………………………..
2. 9olongan darah i0u ………….. 9olongan darah a/ah …………..
2. Natal
a8 Tempat melahirkan : ………………………………………….
0. Jenis persalinan : …………………………………………….
-. "enolong persalinan : …………………………………………
e. Komplikasi /ang dialami oleh i0u pada saat melahirkan dan setelah melahirkan :
............................................................................................................................................
NERS 04 STIKES NH MAKASSAR
3. "ost natal
a. Kondisi 0a/i : ……………………………. A"9A, ………………………………….
0. Anak pada saat lahir tidak mengalami : ……………………………………………….
%1ntuk semua 1sia'
: Klien pernah mengalami pen/akit : ……………………….pada umur : …………………..
di0erikan o0at oleh : …………………………………………..
: ,i5a/at ke-elakaan : ……………………………………………………………………………
: ,i5a/at mengkonsumsi o0at;o0atan 0er0aha/a tanpa an&uran dokter dan menggunakan
<at/su0tansi kimia /ang 0er0aha/a : …………………………………………………………….
: "erkem0angan anak di0anding saudara;saudaran/a : ...................................................................
4. ,i5a/at Kesehatan Keluarga
: 9enogram
Ket :
I=. ,i5a/at Immunisasi %imunisasi lengkap'
N. Jenis immunisasi >aktu pem0erian ?rekuensi ,eaksi setelah pem0erian ?rekuensi
1. B49
2. *"T %I8II8III'
3. "olio %I8II8III8I='
. 4ampak
!. @epatitis
=. ,i5a/at Tum0uh Kem0ang
A. "ertum0uhan ?isik
1. Berat 0adan : ………………kg
2. Tinggi 0adan :……………. -m.
3. >aktu tum0uh gigi …………………. gigi tanggal ………….........…………..…
Jumlah gigi ...................... 0uah.
B. "erkem0angan Tiap tahap
NERS 04 STIKES NH MAKASSAR
1sia anak saat
1. Berguling : …………… 0ulan
2. *uduk : …………… 0ulan
3. Aerangkak : …………… 0ulan
. Berdiri : …………… tahun
!. Ber&alan : …………… tahun
#. 3en/um kepada orang lain pertama kali : …………… tahun
$. Bi-ara pertama kali : …………… tahun dengan men/e0utkan : ……………
(. Berpakaian tanpa 0antuan : ……………
=I. ,i5a/at Nutrisi
A. "em0erian A3I
........................................................................................................................................................
B. "em0erian susu 2ormula
1. Alasan pem0erian : ……………………………………………………………
2. Jumlah pem0erian : ……………………………………………………………
3. 4ara pem0erian : ……………………………………………………………
"ola peru0ahan nutrisi tiap tahap usia sampai nutrisi saat ini
Usia Jenis Nutrisi Lama Pemberian
=II. ,i5a/at "sikososial
: Anak tinggal 0ersama : ................................................ di : ................................................
: 6ingkungan 0erada di : ................................................
: ,umah dekat dengan : ................................................8 tempat 0ermain ................................................
kamar klien : ................................................
: ,umah ada tangga : ................................................
: @u0ungan antar anggota keluarga : ................................................
: "engasuh anak : ................................................
=III. ,i5a/at 3piritual
: 3upport sistem dalam keluarga : ................................................
: Kegiatan keagamaan : ................................................
NERS 04 STIKES NH MAKASSAR
IB. ,eaksi @ospitalisasi
A. "engalaman keluarga tentang sakit dan ra5at inap
; I0u mem0a5a anakn/a ke ,3 karena : ................................................
; Apakah dokter men-eritakan tentang kondisi anak : ................................................
; "erasaan orang tua saat ini : ................................................
; .rang tua selalu 0erkun&ung ke ,3 : ................................................
; Cang akan tinggal dengan anak : ................................................
B. "emahaman anak tentang sakit dan ra5at inap
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
B. AktiDitas sehari;hari
A. Nutrisi
Kondisi 3e0elum 3akit 3aat 3akit
1. 3elera makan
B. 4airan
Kondisi 3e0elum 3akit 3aat 3akit
1. Jenis minuman
2. ?rekuensi minum
3. Ke0utuhan -airan
. 4ara pemenuhan
4. Eliminasi %BABFBAK'
Kondisi 3e0elum 3akit 3aat 3akit
1. Tempat pem0uangan
2. ?rekuensi %5aktu'
3. Konsistensi
. Kesulitan
!. .0at pen-ahar
*. Istirahat tidur
Kondisi 3e0elum 3akit 3aat 3akit
1. Jam tidur
; 3iang
; Aalam
NERS 04 STIKES NH MAKASSAR
2. "ola tidur
3. Ke0iasaan se0elum tidur
. Kesulitan tidur
E. .lah ,aga
Kondisi 3e0elum 3akit 3aat 3akit
1. "rogram olah raga
2. Jenis dan 2rekuensi
3. Kondisi setelah olah raga
?. "ersonal @/giene
Kondisi 3e0elum 3akit 3aat 3akit
1. Aandi
; 4ara
; ?rekuensi
; Alat mandi
2. 4u-i ram0ut
; ?rekuensi
; 4ara
3. 9unting kuku
; ?rekuensi
; 4ara
. 9osok gigi
; ?rekuensi
; 4ara
9. Akti2itas/Ao0ilitas ?isik
Kondisi 3e0elum 3akit 3aat 3akit
1. Kegiatan sehari;hari
2. "engaturan &ad5al harian
3. "enggunaan alat Bantu akti2itas
. Kesulitan pergerakan tu0uh
NERS 04 STIKES NH MAKASSAR
@. ,ekreasi
Kondisi 3e0elum 3akit 3aat 3akit
1. "erasaan saat sekolah
2. >aktu luang
3. "erasaan setelah rekreasi
. >aktu senggang klg
!. Kegiatan hari li0ur
BI. "emeriksaan ?isik
1. Keadaan umum.....................................................................................................:
2. Kesadaran.............................................................................................................:
3. Tanda 7 tanda Dital :
a. Tekanan darah....................................: ..................................... mm@g
0. *en/ut nadi....................................: ..................................... G / menit
-. 3uhu ........................................................: .....................................
o
4
d. "ernapasan.......................................: ..................................... G/ menit
. Berat Badan..........................................................................................................:
!. Tinggi Badan........................................................................................................:
#. Kepala
Inspeksi
Keadaan ram0ut F @/giene kepala : ..............................................................................
a. >arna ram0ut ...............................................................................:
0. "en/e0aran : ..............................................................................
-. Audah rontok : ..............................................................................
d. Ke0ersihan ram0ut : ..............................................................................
"alpasi
Ben&olan : ada / tidak ada : ..............................................................................
N/eri tekan : ada / tidak ada : ..............................................................................
Tekstur ram0ut : kasar/halus : ..............................................................................
$. Auka
Inspeksi
a. 3imetris / tidak............................................................................................:
0. Bentuk 5a&ah...............................................................................................:
-. 9erakan a0normal.......................................................................................:
d. Ekspresi 5a&ah............................................................................................:
"alpasi
N/eri tekan / tidak : ........................................................................................................
*ata lain : ........................................................................................................
(. Aata
Inspeksi
a. "elpe0ra : Edema / tidak
,adang / tidak
0. 3-lera : I-terus / tidak
-. 4on&ungtiDa : ,adang / tidak
Anemis / tidak
NERS 04 STIKES NH MAKASSAR
d. "upil : ; Isokor / anisokor
; A/osis / midriasis
; ,e2leks pupil terhadap -aha/a : ..................................................
e. "osisi mata :
3imetris / tidak : ..................................................................................................
2. 9erakan 0ola mata : ..................................................................................................
g. "enutupan kelopak mata : ..................................................................................................
h. Keadaan 0ulu mata : ..................................................................................................
i. Keadaan Disus : ..................................................................................................
&. "englihatan : ; Ka0ur / tidak
; *iplopia / tidak
"alpasi
Tekanan 0ola mata : ..................................................................................................
*ata lain : ..................................................................................................
). @idung F 3inus
Inspeksi
a. "osisi hidung...............................................................................................:
0. Bentuk hidung.............................................................................................:
-. Keadaan septum..........................................................................................:
d. 3e-ret / -airan..............................................................................................:
*ata lain : ..................................................................................................
1+. Telinga
Inspeksi
a. "osisi telinga...............................................................................................:
0. 1kuran / 0entuk telinga...............................................................................:
-. Aurikel : ..................................................................................................
d. 6u0ang telinga........................................................: Bersih / serumen / nanah
e. "emakaian alat 0antu...................................................................................:
"alpasi
N/eri tekan / tidak
"emeriksaan u&i pendengaran
a. ,inne...............................................................................................:
0. >e0er..............................................................................................:
-. 35a0a-h..........................................................................................:
"emeriksaan Desti0uler : ..................................................................................................
*ata lain : ..................................................................................................
11. Aulut
Inspeksi
a. 9igi
- Keadaan gigi..............................................................................:
- Karang gigi / karies...................................................................:
- "emakaian gigi palsu.................................................................:
0. 9usi
Aerah / radang / tidak : ..................................................................................................
-. 6idah
Kotor / tidak : ..................................................................................................
d. Bi0ir
NERS 04 STIKES NH MAKASSAR
- 4ianosis / pu-at / tidak : ............................................................................................
- Basah / kering / pe-ah : ............................................................................................
- Aulut 0er0au / tidak : ............................................................................................
- Kemampuan 0i-ara : ............................................................................................
*ata lain : ............................................................................................
12. Tenggorokan
a. >arna mukosa.............................................................................................:
0. N/eri tekan..................................................................................................:
-. N/eri menelan.............................................................................................:
13. 6eher
Inspeksi
Kelen&ar th/roid : Aem0esar / tidak
"alpasi
a. Kelen&ar th/roid........................................................................: Tera0a / tidak
0. Kaku kuduk / tidak......................................................................................:
-. Kelen&ar lim2e................................................................: Aem0esar atau tidak
*ata lain : ..................................................................................................
1. ThoraG dan pernapasan
a. Bentuk dada : ............................................................................
0. Irama perna2asan : ............................................................................
-. "engem0angan di 5aktu 0ernapas..............................................................:
d. Tipe pernapasan : ............................................................................
*ata lain : ............................................................................
"alpasi
a. =okal 2remitus : ............................................................................
0. Aassa / n/eri : ............................................................................
Auskultasi
a. 3uara na2as : =esikuler / Bron-hial / Bron-hoDesikuler
0. 3uara tam0ahan : ,on-hi / >hee<ing / ,ales
"erkusi
,edup / pekak / h/personor / t/mpani
*ata lain : ............................................................................
1!. Jantung
"alpasi
I-tus -ordis : ............................................................................
"erkusi
"em0esaran &antung : ............................................................................
Auskultasi
a. BJ I : ............................................................................
0. BJ II : ............................................................................
-. BJ III : ............................................................................
d. Bun/i &antung tam0ahan : ............................................................................
*ata lain : ............................................................................
1#. A0domen
Inspeksi
a. Aem0un-it : ............................................................................
0. Ada luka / tidak : ............................................................................
NERS 04 STIKES NH MAKASSAR
"alpasi
a. @epar : ............................................................................
0. 6ien : ............................................................................
-. N/eri tekan : ............................................................................
Auskultasi
"eristaltik : ............................................................................
"erkusi
a. T/mpani : ............................................................................
0. ,edup : ............................................................................
*ata lain : ............................................................................
1$. 9enitalia dan Anus : ............................................................................
1(. Ekstremitas
Ekstremitas atas
a. Aotorik
- "ergerakan kanan / kiri : ............................................................................
- "ergerakan a0normal : ............................................................................
- Kekuatan otot kanan / kiri : ............................................................................
- Tonus otot kanan / kiri : ............................................................................
- Koordinasi gerak : ............................................................................
0. ,e2leks
- Bi-eps kanan / kiri : ............................................................................
- Tri-eps kanan / kiri : ............................................................................
-. 3ensori
- N/eri : ............................................................................
- ,angsang suhu : ............................................................................
- ,asa ra0a : ............................................................................
Ekstremitas 0a5ah
a. Aotorik
- 9a/a 0er&alan : ............................................................................
- Kekuatan kanan / kiri : ............................................................................
- Tonus otot kanan / kiri : ............................................................................
0. ,e2leks
- K", kanan / kiri : ............................................................................
- A", kanan / kiri : ............................................................................
- Ba0insk/ kanan / kiri : ............................................................................
-. 3ensori
- N/eri : ............................................................................
- ,angsang suhu : ............................................................................
- ,asa ra0a : ............................................................................
*ata lain : ............................................................................
1). 3tatus Neurologi.
3ara2 7 sara2 -ranial
a. NerDus I %.l2a-torius' : penghidu...............................................................:
0. NerDus II %.pti-us' : "englihatan...............................................................:
-. NerDus III8 I=8 =I %.-ulomotorius8 Tro-hlearis8 A0du-ens'
- Konstriksi pupil : ............................................................................
- 9erakan kelopak mata : ............................................................................
NERS 04 STIKES NH MAKASSAR
- "ergerakan 0ola mata : ............................................................................
- "ergerakan mata ke 0a5ah F dalam...................................................................:
d. NerDus = %Trigeminus'
- 3ensi0ilitas / sensori : ............................................................................
- ,e2leks dagu : ............................................................................
- ,e2leks -ornea : ............................................................................
e. NerDus =II %?a-ialis'
- 9erakan mimik : ............................................................................
- "enge-apan 2 / 3 lidah 0agian depan........................................................................:
2. NerDus =III %A-usti-us'
?ungsi pendengaran : ............................................................................
g. NerDus IB dan B %9losopharingeus dan =agus'
- ,e2leks menelan : ............................................................................
- ,e2leks muntah : ............................................................................
- "enge-apan 1/3 lidah 0agian 0elakang : ...................................................................
- 3uara : ............................................................................
h. NerDus BI %Assesorius'
- Aemalingkan kepala ke kiri dan ke kanan : ..............................................................
- Aengangkat 0ahu : ............................................................................
i. NerDus BII %@/poglossus'
- *eDiasi lidah : ............................................................................
Tanda 7 tanda perangsangan selaput otak
a. Kaku kuduk : ............................................................................
0. Kernig 3ign : ............................................................................
-. ,e2leks Brud<inski : ............................................................................
d. ,e2leks 6asegu : ............................................................................
*ata lain : ............................................................................
BI. "emeriksaan Tingkat "erkem0angan %+ 7 # Tahun '
*engan menggunakan **3T
1. Aotorik kasar
2. Aotorik halus
3. Bahasa
. "ersonal so-ial
BII. Test *iagnostik
H 6a0oratorium
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………..
H ?oto ,otgen8 4T 3-an8 A,I8 1398 EE98 E49
BIII. Terapi saat ini %ditulis dengan rin-i'
NERS 04 STIKES NH MAKASSAR

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