FORMAT PENGKAJIAN ANAK

Tanggal Pengkajian :..........................................................................

Tanggal MRS :..........................................................................

I. IDENTITAS KLIEN
Nama : .........................................................................
Tempat/tgl lahir : .........................................................................
Jenis Kelamin : .........................................................................
Nama ayah/Ibu : .........................................................................
Pekerjaan Ayah : .........................................................................
Pekerjaan Ibu : .........................................................................
Alamat : .........................................................................
Suku bangsa : .........................................................................
Agama : .........................................................................
Biaya ditanggung oleh : .........................................................................
Sumber Informasi : .........................................................................

II. KELUHAN UTAMA :

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

III. RIWAYAT KESEHATAN SEKARANG

a. Riwayat perjalanan penyakit:
...................................................................................................................................
………………………………………………………………………………………
………………………………………………………………………………………

b. Pengobatan sebelumnya:
...................................................................................................................................
...................................................................................................................................
III. RIWAYAT KEHAMILAN DAN KELAHIRAN
1. Prenatal :................................................................................................................
.................................................................................................................
2. Natal :................................................................................................................
.................................................................................................................
3. Postnatal :................................................................................................................
.................................................................................................................

IV. RIWAYAT MASA LAMPAU

1. Penyakit waktu kecil :.................................................................................
2. Pernah dirawat di RS :.................................................................................
3. Obat-obatan yang digunakan :.................................................................................

4. Tindakan (operasi) :.................................................................................

5. Alergi :.................................................................................
6. Kecelakaan :.................................................................................
7. Imunisasi :.................................................................................
V. RIWAYAT KESEHATAN KELUARGA
Penyakit yang pernah diderita anggota keluarga :
.........................................................................................................................................
.........................................................................................................................................
Penyakit yang sedang diderita anggota keluarga :
.........................................................................................................................................
.........................................................................................................................................

VI. RIWAYAT SOSIAL

1. Yang mengasuh : .......................................................................
2. Hubungan dengan anggota keluarga :........................................................................
3. Hubungan dengan teman sebaya :........................................................................
4. Pembawaan secara umum :.......................................................................
5. Lingkungan rumah :........................................................................

VII. KEBUTUHAN DASAR

1. Makanan yang disukai/tidak disukai:
Selera :........................................................................................
 Alat makan yang dipakai :........................................................................................
Pola makan/Jam :........................................................................................
2. Pola tidur:
Kebiasaan sebelum tidur :........................................................................................
Tidur siang :........................................................................................
3. Mandi :........................................................................................
4. Aktifitas bermain :........................................................................................
5. Eliminasi :........................................................................................

VIII. KEADAAN KESEHATAN SAAT INI

1. Diagnosa medis :...........................................................................................
2. Tindakan operasi :...........................................................................................
3. Status Nutrisi :...........................................................................................
4. Status Cairan :...........................................................................................
5. Obat-obatan :...........................................................................................
6. Aktifitas :...........................................................................................
7. Tindakan Keperawatan :...........................................................................................
8. Hasil laboratorium :...........................................................................................
9. X – Ray :...........................................................................................
10. Lain – lain :...........................................................................................

IX. PENGKAJIAN HEAD TO TOE

KEPALA
Rambut :...............................................................................................
Kulit kepala :...............................................................................................
Mata
· Pupil :...............................................................................................
· Sclera .............................................................................................:

· Konjunctiva
· Gg. penglihatan
Hidung
· Bentuk
· Sekresi
· Gg. penciuman
:...............................................................................................
:...............................................................................................
:...............................................................................................
:...............................................................................................
:...............................................................................................
Mulut
· Kebersihan :...............................................................................................
Telinga
· Bentuk :...............................................................................................
· Sekresi :...............................................................................................
· Gg. Pendengaran :...............................................................................................
LEHER
Trachea
· Palpasi :...............................................................................................
Glandula tyroid
· Inspeksi :...............................................................................................
· Palpasi :...............................................................................................
DADA
Paru
· Inspeksi :...............................................................................................
· Palpasi :...............................................................................................
· Perkusi :...............................................................................................
· Auskultasi :...............................................................................................
Jantung
· Inspeksi :...............................................................................................
· Palpasi :...............................................................................................
· Perkusi :...............................................................................................
· Auskultasi :...............................................................................................
ABDOMEN
· Inspeksi :...............................................................................................
· Auskultasi :...............................................................................................
· Palpasi :...............................................................................................
· Perkusi :...............................................................................................

GENETALIA :...............................................................................................
EKSTREMITAS :...............................................................................................
X. PEMERIKSAAN TINGKAT PERTUMBUHAN DAN PERKEMBANGAN
1. Fisik:
a. TB:.......................................................................................................................
b. BB:.......................................................................................................................
c. Gigi:.....................................................................................................................
2. Kemandirian dan Bergaul...........................................................................................
3. Motorik halus.............................................................................................................
4. Kognitif dan Bahasa...................................................................................................
5. Motorik Kasar............................................................................................................

XI. INFORMASI LAIN

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