PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

Pengkajian tanggal : Jam :

Tanggal : MRS No. RM :
Ruang/Kelas : Dx. Masuk :

IDENTITAS ANAK IDENTITAS ORANG TUA

Nama : Nama ayah :
Tanggal lahir : Nama ibu :
Jenis kelamin : Pekerjaan ayah/ibu :
Tanggal MRS : Pendidikan ayah/ibu :
Alamat : Agama :
Diagnosa medis : Suku/bangsa :
Sumber informasi : Alamat :

RIWAYAT SAKIT DAN KESEHATAN

Keluhan Utama :
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Riwayat penyakit saat ini

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RIWAYAT KESEHATAN SEBELUMNYA

Riwayat kesehatan yang lalu
1. Penyakit yang pernah diderita
Demam Kejang Batuk pilek Mimisan Lain-lain..........
2. Operasi : Ya Tidak
3. Alergi : Makanan Obat Udara Debu
Lain-lain.............
4. Imunisasi : BCG (umur..........) Polio.....x (umur..........) DPT.....x (umur.........)
Campak (umur........) Hepatitis.....x (umur.........)
Lain-lain
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RIWAYAT KESEHATAN KELUARGA
1. Penyakit yang pernah diderita keluarga
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2. Lingkungan rumah dan komunitas
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3. Perilaku yang mempengaruhi kesehatan
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4. Persepsi keluarga terhadap penyakit anak
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RIWAYAT NUTRISI
1. Nafsu makan : Baik Tidak Mual Muntah
2. Pola makan : 2x/hari 3x/hari >3x/hari
3. Minum : Jenis..........................., jumlah...............cc/hari
4. Pantangan makan : Ya Tidak
5. Menu makanan :................................................................................

RIWAYAT PERTUMBUHAN
1. BB saat ini :........Kg, TB :........cm, LK :.......cm, LD :.......cm, LLA :.......cm
2. BB lahir........gram BB sebelum sakit :.......Kg
3. Panjang lahir.......cm

RIWAYAT PERKEMBANGAN
1. Pengkajian perkembangan (DDST)
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2. Tahap perkembangan psikososial
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3. Tahap perkembangan psikoseksual
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OBSERVASI DAN PEMERIKSAAN FISIK (ROS: Review of System)
1. Keadaan umum : Baik Sedang Lemah Kesadaran :
2. Tanda vital : TD :........mmHg, Nadi :........x/menit, Suhu :.......oC, RR :.......x/menit
Lain-lain
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PERNAPASAN B1 (Breath)
1. Bentuk dada : Normal Tidak, jenis
2. Pola napas (irama ): Teratur Tidak teratur
3. Jenis : Dispnoe Kussmaul Cheney stokes
Lain-lain.......
4. Suara napas : Vesikuler Stridor Wheezing Ronchi
Lain-lain........
5. Sesak napas : Ya Tidak
6. Batuk : Ya Tidak
7. Retraksi otot bantu napas
Ada : ICS Supraklavikular Suprasternal
Tidak ada
8. Alat bantu pernapasan
Ada : Nasal Masker Respirator
Tidak ada
Lain-lain
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Masalah :

KARDIOVASKULER B2 (Blood)
1. Irama jantung : Reguler Ireguler
2. S1/S2 tunggal : Ya Tidak
3. Nyeri dada : Ya Tidak
4. Bunyi jantung : Normal Murmur Gallop Lain-lain...............
5. CRT : <3 detik >3 detik
6. Akral : Hangat Panas Dingin kering
Dingin basah
7. GCS eye : verbal : motorik : total :
8. Reflek fisiologis : Menghisap Menoleh Menggenggam Moro
Patella Triseps Biseps Lain-lain...............
9. Reflek patologis : Babinsky Budzinsky Kernig Lain-lain...............
10. Istirahat tidur :...........jam/hari,
11. Gangguan tidur :
12. Kebiasaan sebelum tidur
Minum susu Mainan Cerita/dongeng
Lain-lain
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Masalah :

PERSYARAFAN, PENGINDERAAN B3 (Brain)

1. Penglihatan (mata)
1) Pupil : Isokor Anisokor Lain-lain..............
2) Sklera/konjunctiva : Anemis Ikterus Lain-lain..............
3) Gangguan pandangan : Ya Tidak Jelaskan :

2. Pendengaran (telinga)
Gangguan pendengaran : Ya Tidak, Jelaskan :

3. Penciuman (hidung)
1) Bentuk : Normal Tidak, Jelaskan :

2) Gangguan penciuman : Ya Tidak, Jelaskan :

Lain-lain
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Masalah :

PERKEMIHAN B4 (Bladder)
1. Kebersihan : Bersih Kotor
2. Urine; jumlah...........cc/hari, Warna:............................, Bau:......................
3. Alat bantu : Ya Tidak Jenis :
4. Kandung kencing
1) Membesar : Ya Tidak
2) Nyeri tekan : Ya Tidak

5. Bentuk alat kelamin : Normal Tidak normal, sebutkan:

6. Uretra : Normal Hipospadia/epispadia

7. Gangguan : Annuria Oliguria Retensi
Inkontinensia Nocturia
Lain-lain
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Masalah :

PENCERNAAN B5 (Bowel)
1. Makan dan minum
1) Nafsu makan : Baik Menurun Frekuensi:..............x/hari
2) Porsi makan : Habis Tidak Ket:
3) Minum :..........cc/hari, jenis :
2. Mulut dan tenggorokan
1) Mulut : Bersih Kotor Berbau
2) Mukosa : Lembab Kering Stomatitis
3) Tenggorokan : Sakit menelan/nyeri tekan Kesulitan menelan
Pembesaran tonsil Lain-lain..........................
3. Abdomen
1) Perut : Tegang Kembung Ascites
Nyeri tekan
2) Lokasi :
3) Peristaltik :..........x/menit
4) Pembesaran hepar : Ya Tidak
5) Pembesaran lien : Ya Tidak
6) Buang air besar :...........x/hari, Teratur : Ya Tidak
7) Konsistensi : Bau: Warna:
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Masalah :

MUSKULOSKLETAL, INTEGUMEN B6 (Bone and Skin)

1. Muskuloskletal
1) Kemampuan pergerakan sendi : Bebas Terbatas
2) Kekuatan otot

2. Kulit
1) Warna kulit : Ikterus Sianotik Kemerahan Pucat
Hiperpigmentasi
2) Turgor : Baik Sedang Jelek
3) Edema : Ada, Lokasi: Tidak ada
Lain-lain
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Masalah :

ENDOKRIN
1. Tyroid membesar : Ya Tidak
2. Hiperglikemia : Ya Tidak
3. Hipoglikemia : Ya Tidak
4. Luka gangren : Ya Tidak
Lain-lain
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Masalah :

PERSONAL HIGIENE
1. Mandi : ............... x/hari
2. Keramas : ............... x/hari
3. Ganti pakaian : ............... x/hari
4. Sikat gigi : ............... x/hari
5. Memotong kuku : ...............
Lain-lain
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Masalah :

PSIKOSOSIALSPIRITUAL
1. Ekspresi afek dan emosi : Senang Sedih Menangis
Cemas Marah Diam
Takut Lain-lain...........
2. Hubungan dengan keluarga
Akrab Kurang akrab
3. Dampak hospitalisasi bagi anak
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4. Dampak hospitalisasi bagi orang tua
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Masalah :
DATA PENUNJANG (Lab, Foto, USG, dll)