FORMAT PENGKAJIAN ANAK

Nama Mahasiswa : ………………………………

Tempat Praktek : ………………………………
Tanggal Praktek : ………………………………

Pengkajian Dilakukan Tanggal............................................................................jam................WIB

I. IDENTITAS
Inisial Nama : …………………... Alamat : …………
Tempat/tgl.lahir : …………………... Agama : …………
Usia : …………………... Suku Bangsa : …………
Nama Ayah/Ibu : …………………... Pendidikan ayah : …………
Pekerjaan Ayah : …………………... Pendidikan ibu : …………
Pekerjaan Ibu : …………………...

II. RIWAYAT KEPERAWATAN

a. Keluhan Utama (saat masuk RS)
..........................................................................................................................................................................................................................................
b. Keluhan utama (saat pengkajian)
..........................................................................................................................................................................................................................................
c. Riwayat Perjalanan Penyakit
......................................................................................................................................................................................................................................

d. Riwayat Kehamilan dan Kelahiran Anak

Prenatal : ……………………………………………………………........................................

Internatal : ……………………………………………………………........................................

Postnatal : ……………………………………………………………..........................................

d. 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 : …………………………………………….........................

e. Riwayat Keluarga
Genogram

f. Riwayat Sosial
Yang mengasuh : …………………………………….....................
Hubungan dengan anggota keluarga : ……………………………….............................
Hubungan dengan teman sebaya : …………………………………..........................
Pembawaan secara umum : …………………………………….....................
Lingkungan rumah : …………………………………….....................

IV. KEADAAN KESEHATAN SAAT INI

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

V. PENGKAJIAN FISIK
DOMAIN (SAFETY/PROTECTION)
Composmentis ( + ), Apatis ( ), Somnolen ( ), Sopor ( ),Soporocoma ( ) Coma ( )

TTV : Suhu 38,5O C, Nadi........x/min, TD...............mmHg, RR..........x/min

Masalah Keperawatan:
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2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM SENSORI PERSEPSI (DOMAIN 5 PERCEPTION/COGNITION)

a. Kesan Umum
Tampak Sakit: ringan ( ), sedang ( ), berat ( ), pucat ( ), sesak ( ), kejang ( )
b. Kepala
Bentuk:........................ Hematoma( ), Luka( )
Fontanel: cekung ( ), Datar ( ), Keras ( ), Lunak ( )
Rambut: warna...............mudah dicabut ( ), ketombe( ), kutu( )
c. Mata
Mata: jernih( ), mengalir, kemerahan( ), sekret( )
Visus: 6/6( ), 6/300( ), 6/ tak terhingga( ),
Pupil: Isokor( ), anisokor( ), miosis( ), midriasis( ),
reaksi terhadap cahaya: kanan Positif( ), negatif( ), kiri negatif( ) positif( ),
alat bantu: kacamata( ), Softlens( )
Conjungtiva: merah jambu( ), anemis( )
Sklera: Putih( ), Ikterik( )
d. Telinga
Simetri( ), sekret( ), radang( ), Pendengaran: ( ), kurang( ), tuli( )
e. Hidung : Simetris( ), pilek( ), epistaksis( )
f. Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
Masalah Keperawatan:
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2.............................................................................................................................................................................................
3............................................................................................................................................................................................

SISTEM RESPIRASI (DOMAIN 3 ELIMINATION/EXCHANGE, CLASS 4)

g. Jalan nafas: Sputum ( ), warna sputum ( ) konsisitensi:........................................
Batuk ( ) frekuensi:..............................
h. Dada
Bentuk: Simetris ( ), Barrel chest/dada tong( ), pigeon chest/dada burung ( ) benjolan ( ), dll………………..
Paru-paru:
Inspeksi: RR………x/ min,
Palpasi: Normal ( ), ekspansi pernafasan( ), taktil fremitus( )
Perkusi: Normal/ Sonor( ), redup/pekak( ), hiper sonor( )
Auskultasi: irama( ), teratur( ),
Suara nafas: vesicular( ), bronkial( ) Suara Tambahan: Ronki ( ), pleural friction( )

Masalah Keperawatan:
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2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM KARDIOVASKULER (DOMAIN ACTIVITY/REST, CLASS 4)

Jantung
Inspeksi: ictus cordis/denyut apeks( ), normal( ) melebar( )
Palpasi: kardiomegali( )
Perkusi: redup( ), pekak( )
Auskultasi: HR...............x/mnt. Aritmia( ),Disritmia( ) , Murmur ( )

Masalah Keperawatan:
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2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM PENCERNAAN (DOMAIN 2 NUTRITION)

i. Mulut
Trismus ( ), Halitosis ( )
Bibir: lembab( ), pucat( ), sianosis( ), labio/palatoskizis( ), stomatitis( )
Gusi: ( ), plak putih( ), lesi( )
Gigi: Normal( ), Ompong( ), Caries( ), Jumlah gigi:...................
Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
j. Leher
Kaku Kuduk ( ) Simetris( ), Benjolan ( ) Tonsil ( )
Kelenjar Tiroid : normal ( ), pembesaran ( )
Tenggorok : kesulitan menelan ( ), dll..................................................................................................

Kebutuhan Nutrisi dan Cairan

BB sebelum sakit: kg BB sakit: kg
Makanan yang disukai:..........................
Selera makan:...........................
Alat makan yang digunakan:........................
Pola makan( x/ hari):......................
Porsi makan yang dihabiskan:............................
Pola Minum .............................gelas/hari), jenis air minum:.....................................................
k. Abdomen
Inspeksi : Bentuk: simetris( ), tidak simetris( ), kembung( ), asites( ),
Palpasi : massa ( ), nyeri ( )
Kuadran I :
Kuadran II :
Kuadran III :
Kuadran IV :
Auskultasi : bising usus........................x/mnt
Perkusi : Timpani ( ), redup ( )

BAB : warna........................................Frekuensi................................x/hari
Konsisitensi:.................................... lendir ( ), darah ( ), ampas ( ) Konstipasi ( )

Masalah Keperawatan:
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2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM REPRODUKSI (DOMAIN 8 SEXUALITY)

Genitalia dan Anus
Laki-laki
Penis: normal/ada ( ), Abnormal…………………,
Scrotum dan testis: normal( ), hernia( ), hidrokel( )
Anus ; normal/ada ( ), atresia ani( )
Perempuan
Vagina: sekret( ), warna( )
Anus: normal/ada ( ), atresia ani( )
Masalah Keperawatan:
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2.............................................................................................................................................................................................
3............................................................................................................................................................................................

SISTEM PERKEMIHAN (DOMAIN 3 ELIMINATION/EXCHANGE, CLASS 1)

Pola Eliminasi
BAK:
Warna:
Konsistensi:
Frekuensi: x/ hari
Urine Output : cc
Penggunaan Kateter:.............................................................................................
Vesika Urinaria: Membesar .....................Nyeri tekan............................
Gangguan; Anuaria ( ), Oliguria ( ), Retensi Urin ( ), nokturia ( ), Inkontinensia Urin ( ), Poliuria ( ), Dysuria ( )
Jelaskan:...............................................................................................................

Masalah Keperawatan:
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2.............................................................................................................................................................................................
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SISTEM MUSKULO SKELETAL (DOMAIN 13 GROWTH/DEVELOPMENTAL, D.COMFORT,)

l. Ekstremitas
Amelia ( ), Sindaktili ( ), Polidaktili( )
Reflek Pat0logis :
Babinsky ...............................................................................................
Kernig ...................................................................................................
Brudzinsky.............................................................................................
Reflek Fisiologis:
Biceps.................................................................................................................
Triceps...............................................................................................................
Patella.................................................................................................................

Ekstremitas:
Superior (Atas) Inferior (Bawah)
Warna
Edema
Luka
Tremor
Clubbing
Placids
Parese
Kekuatan Otot
(1-5)

Persendian:
Nyeri Sendi ( ), pergerakan sendi:.......................
ROM ( Range Of Motion):

Kekuatan Otot :

Kelainan Otot:

Masalah Keperawatan:
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2.............................................................................................................................................................................................
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SISTEM NEUROBEHAVIOUR (DOMAIN COPING/STRESS TOLERANCE, D. GROWTH)

GCS :.......
E:........................................................................................
V: .......................................................................................
M:.......................................................................................

PEMERIKSAAN TINGKAT PERKEMBANGAN (DDST)

Kemandirian dan bergaul : ……………………………………..................
…………………………………….......,..........

Motorik Halus : ……………………………….........................

………………………………............ ,...............
Kognitif dan bahasa : …………………………………......................
……………………………………....................

Motorik kasar : ……………………………………...................

……………………………………....................
Masalah Keperawatan:
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2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM INTGUMEN (DOMAIN 3 ELIMINATION/EXCHANGE)

Kulit
Warna kulit : Sianosis ( ), I kterus ( ), eritematosus rash ( ), discoid lupus ( ), oedema ( ),
Bula ( ), Ganggren ( ), nekrotik jaringan ( ), Hiperpigmentasi ( )
Echimosis ( ), Petekie ( ) Turgor Kulit: elastis ( ), tidak elastis ( ), berapa lama :

Masalah Keperawatan:
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PERSONAL HYGIENE: (DOMAIN ACTIVITY /REST)

Mandi:...................x/hr
Sikat gigi :........................................x/hr
Ganti Pakaian :..................................x/hr
Memotong kuku:...............................x/mgg

Masalah Keperawatan:
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2.............................................................................................................................................................................................
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KEBUTUHAN ISTIRAHAT DAN POLA TIDUR(DOMAIN ACTIVITY /REST)

Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa saat tidur, dll):
Kebiasaan Tidur siang:......................................jam/hari

Masalah Keperawatan:
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2.............................................................................................................................................................................................
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DOMAIN PERSEPSI DIRI

Perasaaan klien terhadap penyakit yang didieritanya.................................................................................
Persepsi klien terhadap dirinya..............................................................................................................................
Konsep diri.......................................................................................................................................................................
Tingkat kecemasan.......................................................................................................................................................
Citra Diri/Bodi image:.................................................................................................................................................

Masalah Keperawatan:
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2.............................................................................................................................................................................................
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PEMERIKSAAN PENUNJANG:..................................................................................................................

TERAPI:.........................................................................................................................................................
 FORMAT PENGKAJIAN NEONATUS (NICU)

Nama Mahasiswa : ………………………………

Tempat Praktek : ………………………………
Tanggal Praktek : ………………………………

Pengkajian Dilakukan Tanggal................jam................WIB

I. IDENTITAS
Inisial Nama : …………………... Alamat : …………
Tempat/tgl.lahir : …………………... Agama : …………
Usia : …………………... Suku Bangsa : …………
Nama Ayah/Ibu : …………………... Pendidikan ayah : …………
Pekerjaan Ayah : …………………... Pendidikan ibu : …………
Pekerjaan Ibu : …………………...

Berat bayi :
Panjang Badan :

Apgar ScorE :

Usia Gestasi :
Berat Badan : Panjang Badan :
Indikasi persalinan :
Tidak ada ( ) Ada ( )
Aspirasi mekonium :
Denyut jantung janin abnormal ( )
Prolaps tali pusat/lilitan tali pusat ( )
Ketuban pecah dini ( ); beberapa jam :
Berat Ibu
Usia Gravida Partus Abortus

Persalinan:
Pervaginam ( )
Sectio caesarea ( ); Alasan :
Komplikasi kehamilan:
 Tidak ada ( ) Ada ( )
 Perawatan antenatal ( )
 Ruptur plasenta / plasenta previa ( )
 Pre eklampsia / toxcemia ( )
 Suspect sepsis ( )
 Persalinan premature/post matur ( )
 Masalah lain :

A. Pemeriksaan Fisik
Intruksi: Beri tanda cek () pada istilah yang tepat/ sesuai dengan data-data di bawah ini. Gambarkan semua temuan abnormal
secara objektif, gunakan kolom data tambahan bila perlu.

SISTEM PERSEPSI SENSORI (DOMAIN 5 PERCEPTION/COGNITION)

1. Kepala
a. Fontanel anterior Lunak ( ) Tegas ( )Datar ( ) Menonjol ( )
Cekung ( )
b. Sutura sagitalis:Tepat ( ) Terpisah ( ) Menjauh ( )Tumpang tindih ( )
c. Gambaran wajah Simetris ( ) Asimetris ( )
d. Molding ( ) Caput succedaneum ( ) Cephalhematoma ( )

2. Mata
Bersih ( ) Sekresi ( )
Jarak interkantus Sklera: Putih ( ) ikterik ( )

5. Bibir
a. Bibir : normal ( ) sumbing ( )
b. Sumbing langit-langit/palatum ( )

1. Telinga, Hidung, Tenggorok

a. Telinga: Normal ( )Abnormal ( ) Sekret( )
b. Hidung: Simetris ( )Asimetris ( ) Sekret ( ) Nafas cuping hidung ( )
c. Tenggorok: Tonsil( ), radang( )

Masalah Keperawatan:
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2.............................................................................................................................................................................................
3.............................................................................................................................................................................................
SISTEM RESPIRASI

7. Toraks
Simetris ( ) Retraksi dada ( ) Klavikula normal ( )

Paru-paru
a. Suara nafas kanan kiri sama ( ) Tidak sama ( )
b. Suara nafas bersih ( ) ronchi ( ) sekresi ( )
wheezing ( ) vesikuler ( ) tidak spontan ( )
c. Respirasi spontan ( ) Tidak spontan ( )

Alat bantu nafas:

( ) Nasal kanul
( ) O2 / incubator
Konsentrasi O2 : ltr/menit

Masalah Keperawatan:
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2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM KARDIOVASKULER (DOMAIN ACTIVITY/REST)

Jantung
Inspeksi: ictus cordis/denyut apeks( ), normal( ) melebar( )
Palpasi: kardiomegali( )
Perkusi: redup( ), pekak( )
Auskultasi: HR...............x/mnt. Aritmia( ),Disritmia( ) , Murmur ( )
Masalah Keperawatan:
1.............................................................................................................................................................................................
2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM PENCERNAAN (DOMAIN 2 NUTRITION)

Mulut
Trismus ( ), Halitosis ( )
Bibir: lembab( ), pucat( ), sianosis( ), labio/palatoskizis( ), stomatitis( )
Gusi: ( ), plak putih( ), lesi( )
Gigi: Normal( ), Ompong( ), Caries( ), Jumlah gigi:...................
Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
Kebutuhan Nutrisi dan Cairan
BB sebelum sakit: kg BB sakit: kg
Makanan yang disukai:..........................
Selera makan:...........................
Alat makan yang digunakan:........................
Pola makan( x/ hari):......................
Porsi makan yang dihabiskan:............................
Pola Minum .............................gelas/hari) jenis air minum:.....................................................
Abdomen
Inspeksi : Bentuk: simetris( ), tidak simetris( ), kembung( ), asites( ),
Palpasi : massa ( ), nyeri ( )
Kuadran I :
Kuadran II :
Kuadran III :
Kuadran IV :
Auskultasi : bising usus........................x/mnt
Perkusi : Timpani ( ), redup ( )

BAB : warna........................................Frekuensi................................x/hari
Konsisitensi:.................................... lendir ( ), darah ( ), ampas ( )
Konstipasi ( )
Masalah Keperawatan:
1.............................................................................................................................................................................................
2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM REPRODUKSI (DOMAIN 8 SEXUALITY)

Genitalia dan Anus
Laki-laki
Penis: normal/ada ( ), Abnormal…………………,
Scrotum dan testis: normal( ), hernia( ), hidrokel( )
Anus ; normal/ada ( ), atresia ani( )
Perempuan
Vagina: sekret( ), warna( )
Anus: normal/ada ( ), atresia ani( )

Masalah Keperawatan:
1.............................................................................................................................................................................................
2.............................................................................................................................................................................................
3............................................................................................................................................................................................
SISTEM MUSKULO SKELETAL (DOMAIN 13 GROWTH/DEVELOPMENTAL, D.COMFORT,)
Reflek
Moro :
Mengisap :
Rooting :

Dan lain-lain:........................................................................................................................................................

ROM:

Tonus/aktifitas
a. Aktif ( ) Tenang ( ) Letargi ( ) Kejang ( )
b. Menagis keras ( ) lemah ( ) melengking ( )
Sulit menangis ( )

Ekstremitas
Amelia ( ), Sindaktili ( ), Polidaktili( )
Reflek Pat0logis :
Babinsky ...............................................................................................
Kernig ...................................................................................................
Brudzinsky.............................................................................................
Reflek Fisiologis:
Biceps.................................................................................................................
Triceps...............................................................................................................
Patella.................................................................................................................
Masalah Keperawatan:
1.............................................................................................................................................................................................
2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM INTEGUMEN (DOMAIN ELIMINATION/EXCHANGE)

Kulit
a. Warna Pink ( ) pucat ( ) Jaundice ( )
Sianosis pada kuku ( ) sirkumoral ( )
Periorbital ( ) seluruh tubuh ( )
b. Kemerahan (rash) ( )
c. Tanda lahir: ( ); sebutkan:
d. Turgor kulit: elastis ( ) tidak elastis ( ) edema ( ) Lanugo ( )

Suhu
a. Lingkungan
Penghangat radian ( ) Pengaturan suhu ( )
Inkubator ( ) Suhu ruang ( ) Boks terbuka ( )

Masalah Keperawatan:
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2.............................................................................................................................................................................................
3.............................................................................................................................................................................................
DOMAIN 7 ROLE RELATIONSHIP

Struktur keluarga (genogram tiga generasi) :

Budaya:
Suku :
Agama:
Bahasa Utama :
Perencanaan makanan bayi :
Masalah sosial yang penting:
Hubungan orang tua dan bayi:

- Orang terdekat yang dapat dihubungi:

- Orang tua berespon terhadap penyakit: ya ( ) tidak ( )
Respon:
- Orang tua berespon terhadap hospitalisasi: ya ( ) tidak ( )
Respon:

- Riwayat anak lain:

Jenis kelamin anak Riwayat persalinan Riwayat imunisasi

TERAPI

PEMERIKSAAN PENUNJANG