YAYASAN KARUNIA ABADI

SEKOLAH TINGGI ILMU KESEHATAN (STIKES)

INSAN UNGGUL SURABAYA
Kampus : Jl. Raya Kletek, No.4 Sidoarjo, Telp. (031) 7860630; Fax. (031) 7860630

FORMAT PENGKAJIAN
ASUHAN PADA PASIEN BAYI / ANAK SAKIT

Nama Fasilitator : Nama Mahasiswa :

Nilai : NIM :

Tanggal MRS : Jam :

Tempat/ Tgl
No. Register : :
Pengkajian

1. PENGKAJIAN
1.1. ANAMNESE
1.1.1. BIODATA
1. Identitas Pasien (Bayi/Anak)
a. Nama : .........................................................................................
b. Jenis Kelamin :L/P
c. Alamat / Tgl Lahir : .........................................................................................
d. Umur : .........................................................................................
2. Penanggung Jawab Klien / Orang Tua
a. Nama Ibu : ................................. a. Nama Ayah : ..................................
b. Umur : ................................. b. Umur : ..................................
c. Suku/ Bangsa : ................................. c. Suku/ Bangsa : ..................................
d. Agama : ................................. d. Agama : ..................................
e. Pendidikan : ................................. e. Pendidikan : ..................................
f. Pekerjaan : ................................. f. Pekerjaan : ..................................
g. Alamat : ................................. g. Alamat : ..................................
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1.1.2. Keluhan Pasien
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STIKES Insan Unggul Surabaya

1.1.3. Riwayat Kesehatan Sekarang
(Diuraikan dari timbulnya gejala penyakit sampai sekarang)
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1.1.4. Riwayat Kesehatan Sebelum Sakit Ini :
a. Riwayat Prenatal : .........................................................................................
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b. Riwayat Intranatal : .........................................................................................
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c. Riwayat Postnatal :
1) Pertumbuhan : .........................................................................................
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2) Perkembangan : .........................................................................................
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1.1.5. Riwayat Kesehatan Keluarga
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1.1.6. Kebutuhan Dasar Khusus
1) Pola Nutrisi : .........................................................................................
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2) Pola Eliminasi : .........................................................................................
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3) Pola Hygiene : .........................................................................................
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STIKES Insan Unggul Surabaya

 4) Istirahat Tidur : .........................................................................................
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5) Aktifitas & Lat./Bermain : .........................................................................................
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6) Kebiasaan Lain : .........................................................................................
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1.2. PEMERIKSAAN FISIK
1.2.1. Tanda-tanda Vital :
1. Kesadaran : ................................................................................................
2. Tensi : ................................................................................................
3. Nadi : ................................................................................................
4. Respirasi : ................................................................................................
5. Suhu : ................................................................................................
1.2.2. Antropometri :
1. Berat Badan : ................................................................................................
2. Tinggi Badan : ................................................................................................
3. Lingkar Kepala : ................................................................................................
4. Lingkar Lengan : ................................................................................................
5. Lingkar Dada : ................................................................................................
1.2.3. Pemeriksaan Secara Umum
1. Kepala : ................................................................................................
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2. Muka : ................................................................................................
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3. Mata : ................................................................................................
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4. Hidung : ................................................................................................
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5. Mulut : ................................................................................................
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6. Leher : ................................................................................................
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7. Dada : ................................................................................................
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8. Perut : ................................................................................................
STIKES Insan Unggul Surabaya
 ....................................................................................................................................
9. Genetalia : ................................................................................................
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10. Ektrimitas : ................................................................................................
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1.3. PEMERIKSAAN LABORATORIUM
1. Darah :
a. Hb : ..............................................................................................
b. Golongan : ..............................................................................................
2. Urine :
Albumin : ..............................................................................................
Reduksi : ..............................................................................................
1.4. PEMERIKSAAN LAIN
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1.5. TERAPY
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1.6. DATA TAMBAHAN
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Mengetahui ......................, Tgl……………………..

CI / Ka. Ruangan Pemeriksa

(………………………………………….) (………………………………………….)

STIKES Insan Unggul Surabaya

 ANALISA DATA
No. Tgl/ Jam Data Penyebab Masalah

Diagnosa Keperawatan
1. ..............................................................................................................................................
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2. ..............................................................................................................................................
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3. ..............................................................................................................................................
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STIKES Insan Unggul Surabaya
 RENCANA KEPERAWATAN
Nama / Inisial Pasien : …………………………
No RM : …………………………
Diagnosa Medis : …………………………
No Diagnosa Tujuan Intervensi Rasional

STIKES Insan Unggul Surabaya

 IMPLEMENTASI KEPERAWATAN
Nama / Inisial Pasien : …………………………
No RM : …………………………
Diagnosa Medis : …………………………
No Diagnosa Tgl/ Jam Implementasi Tgl/ Jam Evaluasi

STIKES Insan Unggul Surabaya

 CATATAN PERKEMBANGAN

No. Hari/ Tgl Diagnosa Catatan Perkembangan (SOAPI)

Mengetahui ………………., Tgl ………………………

CI/ Ka. Ruangan Penyusun

( ………………………………………….) ( ………………………………………….)

STIKES Insan Unggul Surabaya