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

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

I. IDENTITAS
A. Anak
1. Nama : .............................................................................................
2. Anak yang ke : .................
3. Tanggal lahir/umur: ....................
4. Jenis kelamin : .................
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 : .................

1
 II. GENOGRAM

III. ALASAN DIRAWAT

a) Keluhan Utama :
....................
....
....................
b) Riwayat Penyakit :
....................




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

2
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 ...................
....................................................................................................................................

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

3
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 ................................................................................
....................................................................................................................................

4
 Anak-anak
Keadaan sebelum sakit :

............................................................................................................................
....
....................................
....................................................................................................................................
....................................................................................................................................
Keaadan saat sakit :
....................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

C. Eliminasi (BAB/BAK)


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

D. Aktifitas
Permainan :
....................................................................................................................................
........................

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

5
E. Rekreasi
....................................


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

F. Istirahat dan tidur

Kebiasaan istirahat.



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

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

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

H. Pengaturan suhu tubuh

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

6
 ....................
....................................................................................................................................

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

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

J. Rasa aman

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

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

K. Belajar (anak dan orangtua)

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



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

L. Prestasi
........................................................


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

7
M. Hubungan sosial anak

N. Melaksanakan ibadah

8
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

VII. PENYAKIT YANG PERNAH DIDERITA

No Jenis Akut/Kronis Umur Lamanya Pertolongan

Penyakit
..................................
..................................
..................................
/Menular/tidak Saat
Sakit
.............................. ...............
.............................. ...............
.............................. ...............
................. .......................
................. .......................
................. .......................

9
 .................................. .............................. ............... ................. .......................
.................................. .............................. ............... ................. .......................

VIII. KESEHATAN LINGKUNGAN

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

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

IX. PERKEMBANGAN ANAK (0 6 tahun)

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




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

10
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 : ..................................................................................................

11
 Suara nafas : .........................................................................................................
Gangguan lain : .........................................................................................................
J. Telinga
Kebersihan : .........................................................................................................
Alat pendengaran : .........................................................................................................
Kelainan :......................................
K. Mulut
Bibir : .........................................................................................................
Mulut dan tenggorokan : .................................................................................................
Gigi : .........................................................................................................
Lidah : .........................................................................................................
L. Leher
Pembesaran tyroid : ........................................................................................................
Pembesaran limfoid : ......................................................................................................
Kaku kuduk : .........................................................................................................
Pergerakkan leher : .........................................................................................................
M. Thoraks
Bentuk dada : .........................................................................................................
Irama pernafasan : .........................................................................................................
Tarikan otot bantu pernafasan : .......................................................................................
Suara nafas : .........................................................................................................
N. Jantung
Bunyi : .........................................................................................................
Pembesaran : .........................................................................................................
O. Persarafan :
Reflek fisiologis : .........................................................................................................
Reflek patologis : .........................................................................................................
P. Abdomen :
Bentuk : .........................................................................................................
Pembesaran organ : .........................................................................................................
Keadaan pusat : .........................................................................................................

12
 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
5. Lingkar lengan = cm
U. Gejala kardinal :
1. Suhu =
2. Nadi =
3. Pernafasan =
4. Tekanan darah =

13
XI. PEMERIKSAAN PENUNJANG

14
XII. HASIL OBSERVASI
1. Interaksi anak dengan orang tua
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
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..........................................................................................................................................
2. Bentuk/arah komunikasi
..........................................................................................................................................
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3. Ambivalensi/kontradiksi Prilaku
..........................................................................................................................................
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..........................................................................................................................................
4. Rasa aman anak
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

15
 XIII. DIAGNOSA KEPERAWATAN
ANALISIS DATA
Tgl/Jam Data Fokus
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Standar Normal
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16
Interpretasi/Penyebab
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Masalah
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17
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 ANALISIS MASALAH
Masalah Analisis Masalah

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18
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19
DIAGNOSA KEPERAWATAN

No Tgl Muncul Diagnosa Keperawatan

...................................................................................................................................
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20
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21
XIV. RENCANA KEPERAWATAN
A. PRIORITAS DIAGNOSA KEPERAWATAN
..........................................................................................................................................
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22
 ..........................................................................................................................................
..........................................................................................................................................
B. RENCANA TINDAKAN

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

Hasil /TTD
.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
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.................................. ............................. ...................................... ........................
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.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
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23
.................................. ............................. ...................................... ........................
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.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
.................................. ............................. ...................................... ........................
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.................................. ............................. ...................................... ........................

24
 XV TINDAKAN KEPERAWATAN

No Tanggal/ No Implementasi Evaluasi Nama/

Jam DX TTD

............................................................ .......................................................
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25
............................................................ .......................................................
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26
 XVI EVALUASI SUMATIF
No Tanggal/ jam
Diagnosa
................................ ................. ...............................................................................................
................................ ................. ...............................................................................................
................................ .
................................
Nomor Evaluasi Nama/
TTD
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27
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28
29