(Ruang Infeksi dan non infeksi)

ILMU KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

FORMAT PENGKAJIAN

1. IDENTITAS PASIEN
Inisial Pasien :........................................
Usia :........................................
Jenis Kelamin :........................................
Diagnosa Medis :........................................
Tanggal Masuk RS :........................................
Tanggal Pengkajian :........................................
Nama Ayah / Ibu :........................................
Pekerjaan Ayah/Ibu :........................................
Pendidikan Ayah/Ibu :........................................
Alamat :........................................

2. KELUHAN UTAMA
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

3. RIWAYAT KEHAMILAN
a. Pre natal
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
b. Intra natal
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
c. Post natal
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

4. RIWAYAT KESEHATAN YANG LALU

a. Penyakit yang pernah diderita
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

b. Riwayat dirawat di RS
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
 c. Riwayat Konsumsi obat-obatan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
d. Riwayat Operasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
e. Riwayat Alergi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
f. Riwayat Imunisasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
g. Lain-lain
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

5. RIWAYAT KESEHATAN KELUARGA

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

6. GENOGRAM (minimal 3 generasi)

7. RIWAYAT SOSIAL
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

8. KEBUTUHAN DASAR
a. Makan :..........................................................................................................
..........................................................................................................
 ..........................................................................................................
b. Minum :..........................................................................................................
..........................................................................................................
..........................................................................................................
c. Tidur :..........................................................................................................
..........................................................................................................
..........................................................................................................
d. Eliminasi :..........................................................................................................
..........................................................................................................
..........................................................................................................
e. Aktivitas bermain :..........................................................................................................
..........................................................................................................
..........................................................................................................

9. PEMERIKSAAN FISIK
a. Keadaan Umum :..........................................................................................................
..........................................................................................................
..........................................................................................................
..........................................................................................................
b. TB/BB :..........................................................................................................
c. Lingkar Kepala :..........................................................................................................
d. Tnda vital
- TD :..........................................................................................................
- HR :..........................................................................................................
- RR :..........................................................................................................
- Suhu :..........................................................................................................
e. Mata :..........................................................................................................
..........................................................................................................
f. Hidung :..........................................................................................................
..........................................................................................................
g. Mulut :..........................................................................................................
..........................................................................................................
h. Telinga :..........................................................................................................
..........................................................................................................
i. Dada :..........................................................................................................
..........................................................................................................

j. Jantung :..........................................................................................................
..........................................................................................................
k. Paru-paru :..........................................................................................................
..........................................................................................................
..........................................................................................................
l. Abdomen :..........................................................................................................
..........................................................................................................
m. Punngung :..........................................................................................................
..........................................................................................................
n. Genitalia :..........................................................................................................
..........................................................................................................
o. Ekstremitas :..........................................................................................................
..........................................................................................................
p. Kulit :..........................................................................................................
..........................................................................................................
10. PEMERIKSAAN STATUS NUTRISI
a. Klinik :..................................................................................................................................
b. BB/U :..................................................................................................................................
c. TB/U :..................................................................................................................................
d. BB/TB :..................................................................................................................................
e. Simpulan:...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

11. PEMERIKSAAN PENUNJUANG

a. Laboratorium

Tgl Pemeriksaan Jenis Pemeriksaan Hasil Nilai Normal

b. Rontgen
.................................................................................................................................................
.................................................................................................................................................
c. Terapi dan pemeriksaan lainnya
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
12. PEMERIKSAAN TINGKAT PERKEMBANGAN SEBELUM DIRAWAT
a. Kemandirian dalam bergaul
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
b. Motorik halus
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
c. Motorik kasar
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
d. Kognitif dan bahasa
 .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

13. RUMUSAN MASALAH

a. Analisa Data

Analisa Data Masalah Keperawatan yang

Data
(Pohon Masalah) muncul (NANDA)
Data Analisa Data Masalah Keperawatan yang
(Pohon Masalah) muncul (NANDA)
 Analisa Data Masalah Keperawatan yang
Data
(Pohon Masalah) muncul (NANDA)
 Analisa Data Masalah Keperawatan yang
Data
(Pohon Masalah) muncul (NANDA)
 b. Masalah Keperawatan
1) ...........................................................................................................................................
2) ...........................................................................................................................................
3) ...........................................................................................................................................
4) ...........................................................................................................................................
5) ...........................................................................................................................................
6) ...........................................................................................................................................
7) ...........................................................................................................................................
8) ...........................................................................................................................................

14. DIAGNOSA KEPERAWATAN

a. .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
b. .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
c. .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
d. .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
e. .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
f. .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
g. .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
h. .................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
15. RENCANA ASUHAN KEPERAWATAN (NURSING CARE PLANNING)

Diagnosa Keperawatan
No Tujuan Intervensi Keperawatan Rasional
(NANDA)
 Diagnosa Keperawatan
No Tujuan Intervensi Rasional
(NANDA)
 Diagnosa Keperawatan
No Tujuan Intervensi Rasional
(NANDA)
 Diagnosa Keperawatan
No Tujuan Intervensi Rasional
(NANDA)
No Diagnosa Keperawatan Tujuan Intervensi Rasional
(NANDA)
 Diagnosa Keperawatan
No Tujuan Intervensi Rasional
(NANDA)
16. CATATAN PERKEMBANGAN

Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)

Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)
Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)
Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)
Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)
Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)
Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)