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 :

No. Register : Tempat/ Tgl 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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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 : ..............................................................................................
.........................................................................................................................................
.........................................................................................................................................
2) Pola Eliminasi : ..............................................................................................
.........................................................................................................................................
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3) Pola Hygiene : ..............................................................................................
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 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 : .....................................................................................................
.........................................................................................................................................
2. Muka : .....................................................................................................
.........................................................................................................................................
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 : .....................................................................................................
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 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

(………………………………………….) (………………………………………….)
 ANALISA DATA
No. Tgl/ Jam Data Penyebab Masalah

Diagnosa Keperawatan
1. ..............................................................................................................................................
..............................................................................................................................................
2. ..............................................................................................................................................
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3. ..............................................................................................................................................
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 RENCANA KEPERAWATAN
Nama / Inisial Pasien : …………………………
No RM : …………………………
Diagnosa Medis : …………………………
No Diagnosa Tujuan Intervensi Rasional
 IMPLEMENTASI KEPERAWATAN
Nama / Inisial Pasien : …………………………
No RM : …………………………
Diagnosa Medis : …………………………
No Diagnosa Tgl/ Jam Implementasi Tgl/ Jam Evaluasi
 CATATAN PERKEMBANGAN

No. Hari/ Tgl Diagnosa Catatan Perkembangan (SOAPI)

Mengetahui …………., Tgl ……………

CI/ Ka. Ruangan Penyusun

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