AKADEMI KEPERAWATAN

PEMERINTAH KOTA PASURUAN

FORMAT PENGKAJIAN ANAK

Nama Mahasiswa :
NIM :

Tanggal Praktek :
Tanggal Pengkajian :

1. IDENTITAS PASIEN
Nama Pasien : No. Reg :
Jenis Kelamin : Tanggal masuk :
Umur : Ruang :
Agama :
Bangsa /suku :
Bahasa yang dipakai :
Status anak :
Tanggal lahir :
Anak ke berapa :

Nama Orang tua :

Umur :
Agama :
Bangsa /suku :
Pendidikan :
Pekerjaan :
Alamat rumah :

2. INFORMASI MEDIK
Diagnosa Medik :
Waktu/pemeriksaan sebelum MRS :
Obat terakhir yang didapat :
Alergi obat :
Dikirim oleh :

3. RIWAYAT KEHAMILAN DAN KELAHIRAN

a. Prenatal :.............................................................................................
b. Natal :.............................................................................................
c. Postnatal :.............................................................................................

4. RIWAYAT TUMBUH KEMBANG:

a. Keadaan Waktu Lahir :
.................................................................................................................
.................................................................................................................
b. Keadaan Mental /Emosi Anak :
.................................................................................................................
.................................................................................................................
c. Pemeriksaan Perumbuhan :
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………………………………………....

d. Pemeriksaan Perkembangan :
 .................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

5. RIWAYAT PENYAKIT
a. Keluhan Utama :
.................................................................................................................
................................................................................................................
b. Riwayat Penyakit Sekarang :
.................................................................................................................
................................................................................................................
.................................................................................................................
................................................................................................................

c. Riwayat Penyakit Masa Lalu :

.................................................................................................................
................................................................................................................
d. Riwayat Penyakit Keluarga :
.................................................................................................................
................................................................................................................
e. Riwayat Imunisasi
.................................................................................................................
................................................................................................................

6. POLA KEBIASAAN PEMELIHARAAN DAN KESEHATAN

a. Pola makan dan minum
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

b. Pola istirahat tidur :

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

c. Pola aktifitas :
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

d. Pola eliminasi :
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

e. Pola kebersihan diri

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

7. PENGKAJIAN FISIK :
a. Keadaan Umum :
...............................................................................................................
...............................................................................................................

b. Tanda-tanda vital :
.................................................................................................................
...............................................................................................................

c. Kepala :
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

d. Mata /penglihatan :
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

e. Telinga /Pendengaran
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

f. Hidung/penciuman
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

g. Mulut :
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

h. Leher :
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

i. Dada :
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

j. Abdomen/pencernaan :
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

k. Anus Rektum
.................................................................................................................
.................................................................................................................
 .................................................................................................................
.......................................................................................................

l. Alat Kelamin/Sistem Reproduksi

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

m. Extremitas/anggota badan
.................................................................................................................
.................................................................................................................
.................................................................................................................
...............................................................................................................

n. Kulit/otot/opersendian :
.................................................................................................................
.................................................................................................................
.................................................................................................................
..............................................................................................................

o. Pemeriksaan Neurologi
.................................................................................................................
.................................................................................................................
.................................................................................................................
..............................................................................................................

8. DATA PSIKOSOSIOSPIRITUAL:
Perilaku non verbal :.....................................................................................
Keadaan emosi :...........................................................................................
Pola hubungan dengan orang lain :.............................................................
Orang yang sangat dekat dengan dirinya :..................................................
Ketaatan dalam beribadah :........................................................................
Kegiatan keagamaaan yang dapat mengurangi
stres:.............................................................................................................

9. INFORMASI PENUNJANG
Pemeriksaan laboratorium :........................................................................
Pemeriksaan EKG :.....................................................................................
Pemeriksaan Rontgen :...............................................................................
Pemeriksaan Lain-lain.................................................................................
Terapi sekarang yang diberikan :................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
.....................................................................................................................

10. REAKSI PADA SAAT PENGKAJIAN

Anamnese dilakukan terhadap :....................................................................
Reaksi pasien pada waktu pengkajian :.......................................................
Reaksi keluarga pada waktu Pengkajian :..............................................................

Pasuruan,……………….

(…………………………..)