Praktek Profesi Keperawatan Anak

Fakultas Keperawatan – Universitas Andalas

PENGKAJIAN ANAK

Nama Mahasiswa : ________________ Tanggal Pengkajian : __________________

Tanggal Masuk RS : __________________
No. BP : ________________
No. RM : __________________
Tempat Praktek : ________________

I. IDENTITAS DATA
Nama Anak : ________________ Nama Ibu : __________________
BB/TB : ________________ Pekerjaan : __________________
Tanggal Lahir/Usia : ________________ Pendidikan : __________________
Jenis Kelamin : ________________ Agama : __________________
Pendidikan Anak : ________________ Alamat : __________________
Anak ke : ________________ Diagnosa Medis : __________________

II. KELUHAN UTAMA (ALASAN MASUK RUMAH SAKIT)

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III. RIWAYAT KEHAMILAN DAN KELAHIRAN
a. Prenatal :
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b. Intranatal :
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c. Postnatal :
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IV. RIWAYAT KESEHATAN DAHULU

a. Penyakit yang diderita sebelumnya:
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b. Pernah dirawat di RS:
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Silvina Esa Putri, S.Kep

 Praktek Profesi Keperawatan Anak
Fakultas Keperawatan – Universitas Andalas

c. Obat-obatan yang pernah digunakan:

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d. Alergi:
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e. Kecelakaan:
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f. Riwayat Imunisasi:
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V. RIWAYAT KESEHATAN SAAT INI
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VI. RIWAYAT KESEHATAN KELUARGA
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Genogram Keterangan :

VII. RIWAYAT TUMBUH KEMBANG

a. Kemandirian dan Bergaul :

Silvina Esa Putri, S.Kep

 Praktek Profesi Keperawatan Anak
Fakultas Keperawatan – Universitas Andalas

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b. Motorik Kasar :
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c. Motorik Halus :
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d. Kognitif dan Bahasa :
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e. Psikososial :
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f. Lain-lain :
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VIII. RIWAYAT SOSIAL
a. Yang mengasuh Klien:
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b. Hubungan dengan Anggota Keluarga:
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c. Hubungan dengan Teman Sebaya:
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d. Pembawaan secara Umum:
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e. Lingkungan Rumah :
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Silvina Esa Putri, S.Kep

 Praktek Profesi Keperawatan Anak
Fakultas Keperawatan – Universitas Andalas

IX. PEMERIKSAAN FISIK

a. Keadaan Umum : _________________________________
b. TB/BB : _________cm/___________kg
c. Kepala
- Lingkar Kepala : _________cm
- Rambut Kebersihan :
Warna :
Tekstur :
Distribusi Rambut :
Kuat/Mudah Tercabut :
d. Mata : Simetris/Tidak Simetris
- Sklera :
- Konjunctiva :
- Palpebra :
- Pupil Ukuran :
Bentuk :
Reaksi Cahaya :
e. Telinga : Simetris/Tidak Simetris
- Serumen :
- Pendengaran :
f. Hidung : Simetris/Tidak Simetris
- Septum :
- Sekret :
- Polip :
g. Mulut
- Kebersihan :
- Warna Bibir :
- Kelembapan :
Lidah :
Gigi :
h. Leher
- Kelenjar Getah Bening :
- Kelenjar Tiroid :
- JVP :
i. Dada

Silvina Esa Putri, S.Kep

 Praktek Profesi Keperawatan Anak
Fakultas Keperawatan – Universitas Andalas

- Inspeksi :
- Palpasi :
j. Jantung
- Inspeksi :
- Palpasi :
- Auskultasi :
k. Paru-Paru
- Inspeksi :
- Palpasi :
- Perkusi :
- Auskultasi :
l. Perut
- Inspeksi :
- Palpasi :
- Perkusi :
- Auskultasi :
m. Punggung Bentuk :
n. Ekstremitas
- Kekuatan dan Tonus :
Otot
- Reflek-reflek Atas :
Bawah :
o. Genitalia :
p. Kulit
- Warna :
- Turgor :
- Integritas :
- Elastisitas :
q. Pemeriksaan Neurologis :

X. PEMERIKSAAN TUMBUH KEMBANG

a. DDST
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b. Status Nutrisi

Silvina Esa Putri, S.Kep

 Praktek Profesi Keperawatan Anak
Fakultas Keperawatan – Universitas Andalas

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XI. PEMERIKSAAN PSIKOSOSIAL (Erick H. Erickson)
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XII. PEMERIKSAAN SPIRITUAL
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XIII. PEMERIKSAAN PENUNJANG
Pemeriksaan Diagnostik

Data Laboratorium

XIV. KEBUTUHAN DASAR SEHARI-HARI

No Jenis Kebutuhan Di Rumah/sebelum sakit Di Rumah sakit
1 Makan

2 Minum

3 Tidur

4 Mandi

Silvina Esa Putri, S.Kep

 Praktek Profesi Keperawatan Anak
Fakultas Keperawatan – Universitas Andalas

5 Eliminasi

6 Bermain

XV. RINGKASAN RIWAYAT KEPERAWATAN

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XVI. ANALISA DATA

No. Data Patofisiologi Masalah

Silvina Esa Putri, S.Kep

 Praktek Profesi Keperawatan Anak
Fakultas Keperawatan – Universitas Andalas

XVII. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS

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Silvina Esa Putri, S.Kep

 Praktek Profesi Keperawatan Anak
Fakultas Keperawatan – Universitas Andalas

RENCANA ASUHAN KEPERAWATAN

NO Diagnosa Keperawatan Tujuan dan Kriteria Hasil Intervensi (NIC)

(NOC)

Silvina Esa Putri, S.Kep

Praktek Profesi Keperawatan Anak
Fakultas Keperawatan – Universitas Andalas

Silvina Esa Putri, S.Kep

 Praktek Profesi Keperawatan Anak
Fakultas Keperawatan – Universitas Andalas

CATATAN PERKEMBANGAN

Nama : No RM :

No Hari/Tanggal Diagnosa Implementasi Evaluasi Paraf

Dini Aprisupitha, S.Kep

1741313058