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PENGKAJIAN KEPERAWATAN ANAK USIA 0-18 TAHUN

Nama Mahasiswa :
NIM :
Ruang :
Tanggal Pengkajian :
Tanggal Praktek :
Paraf :

I. IDENTITAS KLIEN
No. Rekam Medis : ……………………………………………………
Nama Klien : ……………………………………………………
Nama Panggilan : ……………………………………………………
Tempat/tanggal lahir : ……………………………………………………
Umur : ……………………………………………………
Jenis kelamin : ……………………………………………………
Bahasa yang dimengerti: ……………………………………………………

Orang tua/wali
Nama Ayah/Ibu/Wali : ……………………………………………………
Pekerjaan Ayah/Ibu/Wali : ……………………………………………………
Pendidikan : ……………………………………………………
Alamat Ayah/Ibu/Wali : ……………………………………………………

II. KELUHAN UTAMA


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III. RIWAYAT KELUHAN SAAT INI
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IV. RIWAYAT KESEHATAN MASA LALU
A. Prenatal
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B. Perinatal dan Postnatal
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C. Penyakit yang Pernah Diderita
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D. Hospitalisasi/Tindakan Operasi

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E. Injury/Kecelakaan
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F. Alergi
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G. Imunisasi dan Tes Laboratorium
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H. Pengobatan
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V. RIWAYAT PERTUMBUHAN
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VI. RIWAYAT SOSIAL
A. Yang Mengasuh
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B. Hubungan Dengan Anggota Keluarga
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C. Hubungan Dengan Teman Sebaya
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D. Pembawaan Secara Umum
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VII. RIWAYAT KELUARGA


A. Sosial Ekonomi
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B. Lingkungan Rumah
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C. Penyakit Keluarga
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D. Genogram

Praktik Profesi Keperawatan Anak


 Keterangan Genogram:

: Laki-laki

: Perempuan

: Sudah meninggak

: Tinggal serumah

: Klien

VIII. PENGKAJIAN TINGKAT PERKEMBANGAN SAAT INI (Gunakan format


DDST)
A. Personal Social
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B. Adaptif Motorik Halus

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D. Motorik Kasar
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Interpretasi:
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Praktik Profesi Keperawatan Anak


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IX. PENGKAJIAN POLA KESEHATAN KLIEN SAAT INI
A. Pemeliharaan dan Persepsi Terhadap Kesehatan
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B. Nutrisi
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C. Cairan
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D. Aktivitas
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E. Tidur dan Istirahat
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F. Eliminasi
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G. Pola Hubungan
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H. Koping/Temperamen dan Disiplin yang Diterapkan

Praktik Profesi Keperawatan Anak


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I. Kognitif dan Persepsi
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J. Konsep Diri
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K. Seksual dan Menstruasi
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Praktik Profesi Keperawatan Anak


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L. Nilai
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X. PEMERIKSAAN FISIK
A. Keadaan Umum
1. Tingkat kesadaran: ...............................................................................................
2. Nadi: ……… x/menit Suhu: ………0C RR: ……… x/menit
TD: ……… mmHg
3. Respon nyeri: ...............................................................................................

4. BB: ………kg TB: ………cm LLA: ………cm LK: ………cm


B. Kulit
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C. Kepala
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E. Telinga
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F. Hidung
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G. Mulut

Praktik Profesi Keperawatan Anak


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H. Leher
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J. Payudara
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K. Paru-paru
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M. Abdomen
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N. Genetalia
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O. Anus dan Rektum
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P. Muskuloskeletal
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Q. Neurologi
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XI. PEMERIKSAAN DIAGNOSTIK PENUNJANG


a. Data Laboratorium yang Berhubungan
Praktik Profesi Keperawatan Anak
No Komponen Hasil Satuan Nilai Normal Interpretasi
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b. Pemeriksaan Radiologi
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c. Hasil Konsultasi
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Praktik Profesi Keperawatan Anak


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d. Pemeriksaan Penunjang Diagnostik Lain
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XII. INFORMASI LAIN (mencakup rangkuman kesehatan klien dari Gizi,
fisioterapis, terapi medis, dll)
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Praktik Profesi Keperawatan Anak