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I. IDENTITAS
A. Anak
1. Nama : .............................................................................................
2. Anak yang ke : .................
3. Tanggallahir/umur: ....................
4. Jeniskelamin : .................
5. Agama : .................
B. Orang tua
1. Ayah
a. Nama :(kandung/tiri)
b. Umur : .................
c. Pekerjaan : .................
d. Pendidikan : .................
e. Agama : .....................
f. Alamat: .................
2. Ibu
a. Nama :(kandung/tiri)
b. Umur : .................
c. Pekerjaan : .................
d. Pendidikan : .................
e. Agama : .................
f. Alamat: .................

II. GENOGRAM

1
III. ALASAN DIRAWAT
a) Keluhan Utama :
....................
....
................
....
b) Riwayat Penyakit :
....................




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....................................................................................................
....................................................................................................
IV. RIWAYAT ANAK (0 6 TAHUN), tergantung penyakit
A. Perawatan dalam masa kandungan :
Dilakukan pemeriksaan kehamilan/tidak...................
....................................................................................................................................
Berapa kali Kapan .....................
....................................................................................................................................
....................................................................................................................................
Tempat di ..........................................................
Kesan pemeriksaan tentang kehamilan .....................
....................................................................................................................................
Obat-obat yang telah diminum ......................
....................................................................................................................................
Imunisasi ...................................................................
Pemeriksaan lain ...............................................
....................................................................................................................................
Penyakit yang pernah diderita ibu..............................................................................
....................................................................................................................................
Penyakit dalam keluarga ...................
....................................................................................................................................

2
 B. Perawatan pada waktu kelahiran :
Umur kehamilan dilahirkan di ..................................................
Ditolong oleh
Berlangsungnya kelahiran (biasa/susah/dengan tindakan)........................................
Lamanya proses persalinan....................
Keadaan bayi setelah lahir ....................
BB lahir PBL LK/LD ....................

V. KEBUTUHAN BIO-PSIKO-SOSIAL-SPIRITUAL DALAM KEHIDUPAN SEHARI-HARI

A. Bernafas
1. Kesulitan bernafas : ada/tidak
2. Kesulitan dirasakan : menarik/mengeluarkan nafas
3. Keluhan yang dirasa : ..........................................................................................
..............................................................................................................................
4. Suara nafas : ........................................................................................................

B. Makan dan minum

Bayi
ASI/PASI : ................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Makanan pendamping ASI : .....................................................................................
....................................................................................................................................
Makanan cair (air buah/sari buah) diberi umur .....................
....................................................................................................................................
Bubur susu diberi umur .....................................
....................................................................................................................................
Nasi tim saring diberi umur ..................................
....................................................................................................................................
Nasi tim diberi umur .....................................
....................................................................................................................................
Makanan tambahan lainnya .. diberi umur.........................................
Pola makan ................................................................................
....................................................................................................................................
Anak-anak
Keadaan sebelum sakit :
............................................................................................................................
..
...
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3
 Keaadan saat sakit :
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C. Eliminasi (BAB/BAK)


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D. Aktifitas
Permainan :
....................................................................................................................................
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E. Rekreasi
....................................


............................................................

F. Istirahat dan tidur

Kebiasaan istirahat :



................................................................................

4
 ....................................................................................................................................
....................................................................................................................................

G. Kebersihan diri
Mandi :
Mandi sendiri/dibantu oleh ...........................
....................................................................................................................................
Di ...........................
Memakai sabun/tidak ........................
Dikeringkan dengan handuk/tidak ........................
Gosok gigi :

........................................

H. Pengaturan suhu tubuh

....................
....................................................................................................................................
....................
...................................................................................................................................

I. Rasa nyaman
....................

............................................
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J. Rasa aman

........................................

............................................

K. Belajar (anak dan orangtua)

............................................................................................................

5
 ................................................................................................................
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L. Prestasi
........................................................


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M. Hubungan sosial anak

N. Melaksanakan ibadah

VI. PENGAWASAN KESEHATAN

Bila sehat diawasi di .............................................................................................................
Bila sakit minta pertolongan kepada....
Kunjungan ke Posyandu ...
................................................................................................................................................
Pengawasan anak dirumah ........................................
................................................................................................................................................
Imunisasi (1 5 tahun)

Imunisasi Umur Tgl diberikan Reaksi Tempat Imunisasi

BCG

DPT I, II, III

HB I, II, III

Campak

Tambahan / anjuran

6
VII. PENYAKIT YANG PERNAH DIDERITA
N Jenis Akut/Kronis UmurSaa Lamanya Pertolongan
Penyakit /Menular/tidak
o t
Sakit
.................................. ............................. ............... ................. .......................
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.................................. . ...........................
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.................................. ............... ................. .......................
..... .......................
..................................
....... .....................
.........

VIII. KESEHATAN LINGKUNGAN

....................

............................................
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IX. PERKEMBANGAN ANAK (0 6 tahun)

(Motorik kasar, motorik halus, bahasa, personal sosial)




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7
X. PEMERIKSAAN FISIK
A. Kesan umum
Kebersihan : .........................................................................................................
Pergerakan : .........................................................................................................
Penampilan/postur/: ........................................................................................................
bentuk tubuh ........................................................................................................
Status Gizi : .........................................................................................................
..........................................................................................................................................
B. Warna kulit (pucat, normal, cyanosis, ikterus, kelainan )
C. Suara waktu menangis :...........
D. Tonus otot :..............
E. Turgor kulit :....................................
F. Udema : ada/tidak, di ..........................................................
G. Kepala
Bentuk : .........................................................................................................
Keaadaan rambut : .........................................................................................................
dan kulit kepala ........................................................................................................
UUB : .........................................................................................................
Kelainan : .........................................................................................................
H. Mata :
Bentuk : .........................................................................................................
Pergerakan : .........................................................................................................
Pupil : .........................................................................................................
Konjungtiva : .........................................................................................................
Kornea : .........................................................................................................
Sclera : ........................................................................................................
Bulu mata dan : ........................................................................................................
ketajaman penglihatan
I. Hidung
Secret : .........................................................................................................
Tarikan cuping hidung : ..................................................................................................
Suara nafas : .........................................................................................................
Gangguan lain : .........................................................................................................
J. Telinga
Kebersihan : .........................................................................................................
Alat pendengaran : .........................................................................................................
Kelainan :......................................
K. Mulut

8
 Bibir : .........................................................................................................
Mulut dan tenggorokan : .................................................................................................
Gigi : .........................................................................................................
Lidah :.........................................................................................................
L. Leher
Pembesaran tyroid : ........................................................................................................
Pembesaran limfoid : ......................................................................................................
Kakukuduk : .........................................................................................................
Pergerakkan leher :.........................................................................................................
M. Thoraks
Bentuk dada : .........................................................................................................
Iramapernafasan : .........................................................................................................
Tarikan otot bantu pernafasan : .......................................................................................
Suara nafas : .........................................................................................................
N. Jantung
Bunyi : .........................................................................................................
Pembesaran : .........................................................................................................
O. Persarafan :
Reflek fisiologis : .........................................................................................................
Reflek patologis : .........................................................................................................
P. Abdomen :
Bentuk : .........................................................................................................
Pembesaran organ : .........................................................................................................
Keadaan pusat : .........................................................................................................
Teraba skibala : .........................................................................................................
Massa : .........................................................................................................
Nyeri : .........................................................................................................
Distensia : .........................................................................................................
Hernia : .........................................................................................................
Peristaltik :.........................................................................................................
Q. Ekstremitas :
Bentuk : .........................................................................................................
Pergerakan : .........................................................................................................
Reflek lutut : .........................................................................................................
Udema : .........................................................................................................
Ujung ekstremitas : .........................................................................................................
Akral : .........................................................................................................
CRT : .........................................................................................................
Lain-lain :.........................................................................................................
R. Alat kelamin : ..................
S. Anus : ..............
T. Antropometri (ukuran pertumbuhan)
1. BB = kg
2. TB = cm
3. Lingkar kepala = cm
4. Lingkar dada = cm

9
 5. Lingkar lengan = cm
U. Gejala kardinal :
1. Suhu =
2. Nadi =
3. Pernafasan =
4. Tekanan darah =

XI. PEMERIKSAAN PENUNJANG

XII. HASIL OBSERVASI

1. Interaksi anak dengan orang tua
..........................................................................................................................................
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10
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2. Bentuk/arah komunikasi
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3. Ambivalensi/kontradiksi prilaku
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4. Rasa aman anak
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..........................................................................................................................................

XIII. DIAGNOSA KEPERAWATAN

ANALISIS DATA

Tgl/Ja Data Fokus Standar Normal Interpretasi/Penyeba Masalah

m b
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Tgl/Ja Data Fokus
m b
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Standar Normal
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Interpretasi/Penyeba
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ANALISIS MASALAH
Masalah Analisis Masalah

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Masalah Analisis Masalah

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DIAGNOSA KEPERAWATAN

No Tgl Muncul Diagnosa Keperawatan

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No Tgl Muncul Diagnosa Keperawatan

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XIV. RENCANA KEPERAWATAN

A. PRIORITAS DIAGNOSA KEPERAWATAN
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B. RENCANA TINDAKAN

No Tgl/jam Dx Keperawatan Tujuan&Kriteria Intervensi Rasional Nama

Hasil /TTD
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No Tgl/jam Dx Keperawatan Tujuan&Kriteria Intervensi Rasional Nama

Hasil /TTD
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26
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No Tgl/jam Dx Keperawatan Tujuan&Kriteria Intervensi Rasional Nama

Hasil /TTD
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28
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XV TINDAKAN KEPERAWATAN

No Tanggal/ No Implementasi Evaluasi Nama/

Jam DX TTD

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No Tanggal/ No Implementasi Evaluasi Nama/
Jam DX TTD
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No Tanggal/ No Implementasi Evaluasi Nama/

Jam DX TTD

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XVI EVALUASI SUMATIF

No Tanggal/ jam Nomor Evaluasi Nama/

Diagnosa TTD
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37

No Tanggal/ jam
Diagnosa
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Nomor Evaluasi Nama/
TTD
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