FORMAT PENGKAJIAN KEPERAWATAN ANAK

Nama Mahasiswa :
NIM :
Tempat Praktek :
Tanggal & jam pengkajian :

I. PENGKAJIAN
A. Identitas pasien
Nama klien : ..............................................................
No. Rekam Medis : ..............................................................
Tanggal lahir/ Umur : ..............................................................
Nama ayah : ..............................................................
Nama Ibu : ..............................................................
Pekerjaan Ayah : ..............................................................
Pekerjaan Ibu : ..............................................................
Alamat : ..............................................................
No. Telp/ HP : ..............................................................
Suku bangsa : ..............................................................
Agama : ..............................................................
Pendidikan terakhir orang tua
Ayah : ..............................................................
Ibu : ..............................................................
Golongan Darah Ibu : ..............................................................
Golongan darah ayah : ..............................................................

B. Riwayat kehamilan dan persalinan

 Prenatal
 Apakah ibu rutin melakukan prenatal care/ pemeriksaan kehamilan ?
........................................................................................................................
........................................................................................................................
 Bagaimana masalah dalam kehamilan
........................................................................................................................
........................................................................................................................ ...........
............................................................................................................. ......................
..................................................................................................

 Natal
 Berat badan waktu lahir .................................................................................
 Tinggi badan ..................................................................................................
 Bagaimana masalah waktu persalinan
........................................................................................................................
........................................................................................................................

 Postnatal
 Apakah ibu rutin melakukan post natal care ?
........................................................................................................................
........................................................................................................................

 Apakah ada masalah pada saat pasca persalinan ?

STIKES SYEDZA SAINTIKA PADANG 1

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

C. Riwayat kesehatan dahulu

 Penyakit yang dialami sebelumnya

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

 Apakah pernah dirawat di Rumah Sakit Ya / Tidak

Kalau YA kapan ? ..............................................................
Berapa lama ? ....................................................................
Masalah apa? ....................................................................

 Apakah pernah mengalami tindakan pembedahan/ operasi ? Ya / Tidak

Kalau YA kapan ? ..............................................................
Jenis pembedahan ? ............................................................

 Apakah pernah mengalami kecelakaan / trauma Ya / Tidak

Kalau YA kapan ? ..............................................................
Jenis Kecelakaan ? ..............................................................

 Apakah alergi terhadap obat-obatan ? Ya / Tidak

Kalau YA, jenis obat yang sensitif ? ..............................................................
..............................................................................................................................
 Imunisasi
Apakah telah di imunisasi lengkap ? Ya / Tidak
Jenis Imunisasi yang telah didapatkan
..........................................................................................................................................
..........................................................................................................................................

D. Riwayat keluarga
Apakah ada anggota keluarga yang pernah mengalami penyakit menular dalam 2
minggu terakhir/ penyakit turunan ?
Ya / Tidak
Kalau YA jenis penyakit apa yang diderita ?
Demam berdarah/ TBC/ Hepatitis A/ Typus/ Diabetes Mellitus/ dll
............................................................................................................................ ............
................................................................................................................

Genogram

STIKES SYEDZA SAINTIKA PADANG 2

 E. Riwayat Sosial
- Yang mengasuh .......................................................................................................
- Hubungan dengan anggota keluarga........................................................................
- Hubungan dengan teman sebaya .............................................................................
- Pembawaan anak secara umum ...............................................................................
F. Kebutuhan dasar
- Makanan yang disukai / tidak disukai
....................................................................................................................
....................................................................................................................
- Selera makan saat dirawat
...................................................................................................................
...................................................................................................................
- Pola makan/minum saat dirawat (jam)
..................................................................................................................
.................................................................................................................
- Pola tidur
a. Kebiasaan sebelum tidur (perlu mainan, diberikan cerita, benda yang dibawa
tidur
dll) ......................................................................................................................
....
b. Jam tidur malam ................................................................................................
c. Apakah suka tidur siang ....................................................................................
d. Jam tidur siang ..................................................................................................
e. Pola tidur selama dirawat (Terganggu/ Tidak Terganggu)
............................................................................................................................
- Eliminasi
a. Urin
Warna..................... Frekuensi BAK.............. Jumlah urin/ 24 jam.................cc
b. Feses
Konsistensi ....................... Warna.............. Kesimpulan: Normal/ Melena
- Aktivitas bermain sebelum sakit
Senang bermain dengan kelompok ? Ya / Tidak
Senang bermain sendiri ? Ya / Tidak

G. Keadaan kesehatan sekarang

 Keadaan umum: ....................................... dengan GCS ......... (E M V )
 Keluhan utama saat pengkajian
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Alasan masuk RS/kunjungan ke poliklinik

STIKES SYEDZA SAINTIKA PADANG 3

 .....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Diagnosa Medis
.....................................................................................................................................
.....................................................................................................................................
 Tindakan operasi / prosedur yang dialami
.....................................................................................................................................
.....................................................................................................................................
 Obat-obatan yang dipakai saat ini
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Status nutrisi saat ini (sertakan lampiran grafik NHCS)
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Status balance cairan
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Kesimpulan: ...............................................................................................................
 Aktifitas selama sakit
.....................................................................................................................................
.....................................................................................................................................
 Hasil laboratorium (Sertakan tanggal dan nilai normal)
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

STIKES SYEDZA SAINTIKA PADANG 4

 .....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Hasil pemeriksaan penunjang
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Lain – lain
.....................................................................................................................................
.....................................................................................................................................

H. Pemeriksaan fisik
 Data umum :
........................................................................................................................
........................................................................................................................ .............
........................................................................................................... ..........................
.............................................................................................. .......................................
.................................................................................
 Berat badan : .....................................................................
 Tinggi badan : .....................................................................
a. Wajah : Presentasi wajah khas (.....), micognathia (......),moonface
(.......)
b. Kepala : bentuk kepala (mikrocephali/ anensephali/ hidrosephalus),
jarak sutura (normal/ melebar), fontanel mayor (tegang/ menonjol/cekung), caput
succadenum (.....), Mollage (.....), crackpot sign (.......), lingkar kepala .............
cm
c. Mata : Cekung/ tidak cekung, Strabismus (....), jarak 2 epikantus
(...................), Pupil Isokor/ Unisokor, diameter pupil (.........../...........), sunset
eyes (....), konjunctiva (anemis/ non anemis), sklera (ikterik/ tidak ikterik)
d. Telinga : .....................................................................
e. Hidung : Nafas cuping hidung (.......), Sumbatan Mukus (.......),
Concha Nasal (................), Penggunaan NGT (.......), Penggunaan oksigenasi
(.....); jenis masker(.....................................), aliran O2 (............lt/menit)
f. Mulut : Labioskizis/ Palato skizis/ Labio-Palatoskizis,
membran mukosa bibir (................................), perdarahan gusi (.............),

STIKES SYEDZA SAINTIKA PADANG 5

 keadaan lidah (lidah kotor/ lidah berwarna pink/ lidah tremor), sekret/ mukus
(.........................................), selaput putih pada uvula (.........)
g. Leher : JVP (..............................), pembesaran kelenjar getah
bening (........)
h. Dada : bentuk dada (Normochest/ Pigeon Chest/ Barrel Chest/
Funnel Chest/ Flat Chest)
 Paru- paru :
I : karakteristik pernafasan (normal/ cheyne stokes/ kussmaul/ Apneustik/
Apnea/ Orthopnea), pergerakan rongga torak (Simetris/ Tidak Simetris),
Retraksi Intercostae (........), penggunaan otot bantu nafas (Sternocleido
mastoideus/ Serratus Anterior/ Supra clavicula)
Pal : Vocal fremitus (kiri/ kanan)/ Tidak teraba fremitus (kiri/ kanan)
Per : Sonor/ Hipersonor/ Dullness
Aus : Vesikuler (......), Bronchovesiculer (.....); Wheezing (.......), Ronchi
(........), Krekels (........) pada .......................... .........................lapang
paru ; Suara nafas (Paten/ Gurgling/ Stridor)
 Jantung
I : Ictus cordis terlihat/ tidak terlihat
Pal : Impuls apex (......) pada RIC .................................................., Trill (......)
Per : Tympani pada batas jantung di .................................................................
..........................................................................................................................
Aus : Bunyi jantung normal/ tidak normal (Murmur/ Gallop)
i. Abdomen :
Insp : Distensi abdomen (....), Meteorismus (.....), Ascites (.......), Hernia
abdominal (......), ostomi (........); jenis
stoma..................................... ...............
Aus : bising usus (...........kali/ menit)
Per : Dullness (.......), Tympani (.....), Turgor (baik/ jelek)
Pal : Hepatomegali (.....), Splenomegali (.....), Nyeri tekan/ nyeri lepas/ nyeri
diffus (.....) pada titik McBurney/ Kuadran ....................
j. Punggung : postur spine (Normal/ Skeliosis/ Kifosis/ Lordosis),
dekubitus (.......) lebar luka (.........................), panjang luka (.................................
............), dalam luka (....................................), ada/ tidak ada pus/ eksudat/
transudat/ nekrosis
k. Ekstremitas : Udem pretibia/ dorsalis pedis (........), Sianosis perifer
(......), Akral teraba (............), CRT .......... detik, persendian terlihat normal/ tidak
normal (.......................................),tonus otot :

l. Genitalia : Udem (......), Hernia Inguinalis (........), kebersihan

genitalia .............................................................
m. Anus : Ada/ atresia ani
n. Integumen
Insp : Warna kulit (............................), hidrasi kulit (.........................................),
ptekie (......), Ikterik (......) derajat ................ pada bagian ......................................

STIKES SYEDZA SAINTIKA PADANG 6

 ..................................................................................................................................
hematoma (....) pada ......................................................, purpura (.....) pada .........
....................................................................., luka (.....) pada .................................
...........................................dengan karakteristik luka .............................................
.................................................................................................................................
Udem (............................................................), diaforesis (.......)
Palpasi: Pitting udem (........................), Suhu kulit teraba .....................................
o. Tanda-tanda vital

Tekanan darah : ....................... Respirasi rate:...................

Nadi :......................... Suhu Tubuh :....................

 Pemeriksaan tumbuh kembang

a. Kemandirian dan bergaul
..................................................................................................................
.................................................................................................................
b. Motorik halus
..................................................................................................................
.................................................................................................................
c. Motorik kasar
..................................................................................................................
.................................................................................................................
d. Kognitif dan bahasa
..................................................................................................................
.................................................................................................................
e. Informasi lain
.................................................................................................................
.................................................................................................................

I. Keadaan Psikososial Anak dan Orang tua/ Care giver

 Kemampuan orang tua/ care giver untuk bekerja sama dalam setiap asuhan
keperawatan.......................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
 Bagaimana ansietas anak saat dirawat/ kunjungan poliklinik (menghambat/ tidak
menghambat tindakan asuhan keperawatan)
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
 Bagaimana ansietas orang tua/ care giver saat anak di rawat/ kunjungan poliklinik
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
J. Kebutuhan Edukasi pada Orang Tua dan/ atau Anak
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

STIKES SYEDZA SAINTIKA PADANG 7

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

FORMAT PENGKAJIAN KEPERAWATAN ANAK PADA NEONATUS DAN

BAYI
Nama Mahasiswa :
NIM :
Tempat Praktek :
Tanggal & jam pengkajian :

STIKES SYEDZA SAINTIKA PADANG 8

II. PENGKAJIAN
I. Identitas pasien
Nama klien : ..............................................................
No. Rekam Medis : ..............................................................
Tanggal lahir/ Umur : ..............................................................
Nama ayah : ..............................................................
Nama Ibu : ..............................................................
Pekerjaan Ayah : ..............................................................
Pekerjaan Ibu : ..............................................................
Alamat : ..............................................................
No. Telp/ HP : ..............................................................
Suku bangsa : ..............................................................
Agama : ..............................................................
Pendidikan terakhir orang tua
Ayah : ..............................................................
Ibu : ..............................................................
Golongan darah Ibu : ..............................................................
Golongan darah ayah : ..............................................................

J. Riwayat kehamilan dan persalinan

 Prenatal
 Apakah ibu rutin melakukan prenatal care/ pemeriksaan kehamilan ?
........................................................................................................................
........................................................................................................................
 Obat-obatan yang digunakan ibu selama hamil ............................................
........................................................................................................................
 Asupan nutrisi ibu selama hamil ...................................................................
........................................................................................................................
 Permasalahan ibu selama hamil dan persalinan
........................................................................................................................
........................................................................................................................ ...........
............................................................................................................. ......................
..................................................................................................

 Natal
 Berat badan waktu lahir .................................................................................
 Tinggi badan ..................................................................................................
 Nilai APGAR skor saat lahir ...........................................................

 Postnatal
 Apakah ibu rutin melakukan post natal care?
........................................................................................................................
........................................................................................................................

 Apakah ada masalah pada saat pasca persalinan ?

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

K. Riwayat kesehatan dahulu

 Penyakit yang dialami sebelumnya

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

 Apakah pernah dirawat di Rumah Sakit Ya / Tidak

STIKES SYEDZA SAINTIKA PADANG 9
 Kalau YA kapan ? ..............................................................
Berapa lama ? ....................................................................
Masalah apa? ....................................................................

 Apakah pernah mengalami tindakan pembedahan/ operasi ? Ya / Tidak

Kalau YA kapan ? ..............................................................
Jenis pembedahan ? ............................................................

 Apakah pernah mengalami kecelakaan / trauma Ya / Tidak

Kalau YA kapan ? ..............................................................
Jenis Kecelakaan ? ..............................................................

 Apakah alergi terhadap obat-obatan ? Ya / Tidak

Kalau YA, jenis obat yang sensitif ? ..............................................................
..............................................................................................................................
 Imunisasi
Apakah telah di imunisasi lengkap ? Ya / Tidak
Jenis Imunisasi yang telah didapatkan
..........................................................................................................................................
..........................................................................................................................................

L. Riwayat keluarga
Apakah ada anggota keluarga yang pernah mengalami penyakit menular dalam 2
minggu terakhir/ penyakit turunan ?
Ya / Tidak
Kalau YA jenis penyakit apa yang diderita ?
Demam berdarah/ TBC/ Hepatitis A/ Typus/ Diabetes Mellitus/ dll
............................................................................................................................ ............
................................................................................................................

Genogram

M. Riwayat Sosial
- Yang mengasuh .......................................................................................................
- Hubungan dengan anggota keluarga........................................................................
- Hubungan dengan teman sebaya .............................................................................
- Pembawaan bayi secara umum ...............................................................................
N. Kebutuhan dasar
STIKES SYEDZA SAINTIKA PADANG 10
 - Pola makan/minum ASI saat dirawat (jam)
..................................................................................................................
.................................................................................................................
- Pola tidur
f. Kebiasaan sebelum tidur (perlu mainan, diberikan cerita, benda yang dibawa
tidur
dll) ......................................................................................................................
....
g. Jam tidur malam ................................................................................................
h. Apakah suka tidur siang ....................................................................................
i. Jam tidur siang ..................................................................................................
j. Pola tidur selama dirawat (Terganggu/ Tidak Terganggu)
............................................................................................................................
- Eliminasi
c. Urin
Warna..................... Frekuensi BAK.............. Jumlah urin/ 24 jam.................cc
d. Feses
Konsistensi ....................... Warna.............. Kesimpulan: Normal/ Melena
- Aktivitas bermain sebelum sakit
Senang bermain dengan kelompok ? Ya / Tidak
Senang bermain sendiri ? Ya / Tidak

O. Keadaan kesehatan sekarang

 Keadaan umum: ....................................... dengan GCS ......... (E M V )
 Keluhan utama saat pengkajian
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Alasan masuk RS/kunjungan ke poliklinik
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Diagnosa Medis
.....................................................................................................................................
.....................................................................................................................................
 Tindakan operasi / prosedur yang dialami
.....................................................................................................................................
.....................................................................................................................................
 Obat-obatan yang dipakai saat ini
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

STIKES SYEDZA SAINTIKA PADANG 11

 .....................................................................................................................................
.....................................................................................................................................
 Status nutrisi saat ini (sertakan lampiran grafik NHCS)
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Status balance cairan
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Kesimpulan: ...............................................................................................................
 Aktifitas selama sakit
.....................................................................................................................................
.....................................................................................................................................
 Hasil laboratorium (Sertakan tanggal dan nilai normal)
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Hasil pemeriksaan penunjang
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
STIKES SYEDZA SAINTIKA PADANG 12
 .....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Lain – lain
.....................................................................................................................................
.....................................................................................................................................

P. Pemeriksaan fisik
 Data umum :
........................................................................................................................
........................................................................................................................ .............
........................................................................................................... ..........................
.............................................................................................. .......................................
.................................................................................
 Berat badan : .....................................................................
 Tinggi badan : .....................................................................
a. Wajah : Presentasi wajah khas (.....), micognathia (......)
b. Kepala : bentuk kepala (mikrocephali/ anensephali/ hidrosephalus),
jarak sutura (normal/ melebar), fontanel mayor (tegang/ menonjol/cekung), caput
succadenum (.....), Mollage (.....), lingkar kepala ............. cm , crackpot sign (....)
c. Mata : Cekung/ tidak cekung, Strabismus (....), jarak 2 epikantus
(...................), Pupil Isokor/ Unisokor, diameter pupil (.........../...........), sunset
eyes (....), konjunctiva (anemis/ non anemis), sklera (ikterik/ tidak ikterik)
d. Telinga : .....................................................................
e. Hidung : Nafas cuping hidung (.......), Sumbatan Mukus (.......),
Concha Nasal (................), Penggunaan NGT (.......), Penggunaan oksigenasi
(.....); jenis masker(.....................................), aliran O2 (............lt/menit)
f. Mulut : Labioskizis/ Palato skizis/ Labio-Palatoskizis,
membran mukosa bibir (................................), perdarahan gusi (.............),
keadaan lidah (lidah kotor/ lidah berwarna pink/ lidah tremor), sekret/ mukus
(.........................................)
g. Leher : JVP (..............................), pembesaran kelenjar getah
bening (........)
h. Dada : bentuk dada (Normochest/ Pigeon Chest/ Barrel Chest/
Funnel Chest/ Flat Chest)
a. Paru- paru :
I : karakteristik pernafasan (normal/ cheyne stokes/ kussmaul/ Apneustik/
Apnea/ Orthopnea), pergerakan rongga torak (Simetris/ Tidak Simetris),
Retraksi Intercostae (........), penggunaan otot bantu nafas (Sternocleido
mastoideus/ Serratus Anterior/ Supra clavicula)
Pal : Vocal fremitus (kiri/ kanan)/ Tidak teraba fremitus (kiri/ kanan)
Per : Sonor/ Hipersonor/ Dullness
Aus : Vesikuler (......), Bronchovesiculer (.....); Wheezing (.......), Ronchi
(........), Krekels (........) pada .......................... .........................lapang
paru ; Suara nafas (Paten/ Gurgling/ Stridor)
b. Jantung
I : Ictus cordis terlihat/ tidak terlihat
Pal : Impuls apex (......) pada RIC .................................................., Trill (......)
Per : Tympani pada batas jantung di .................................................................
STIKES SYEDZA SAINTIKA PADANG 13
 ..........................................................................................................................
Aus : Bunyi jantung normal/ tidak normal (Murmur/ Gallop)
i. Abdomen :
Insp : Distensi abdomen (....), Meteorismus (.....), Ascites (.......),
Gastroschizis (.....), Omphalokel (......), Hernia umbilikalis (......), Tali
pusat (....................................................................................................),
ostomi (........); jenis stoma....................................................
Aus : bising usus (...........kali/ menit)
Per : Dullness (.......), Tympani (.....), Turgor (baik/ jelek)
Pal : Hepatomegali (.....), Splenomegali (.....), Nyeri tekan/ nyeri lepas/ nyeri
diffus (.....) pada titik McBurney/ Kuadran ....................
j. Punggung : postur spine (Normal/ Skeliosis/ Kifosis/ Lordosis), Ulkus
(....)
k. Ekstremitas : Udem pretibia/ dorsalis pedis (........), Sianosis perifer
(......), Akral teraba (............), CRT .......... detik, persendian terlihat normal/ tidak
normal (.......................................)
l. Genitalia : Udem (......), Hernia Inguinalis (........), Labia mayora
menutupi labia minora (.....), Testis turun ke skrotum (....), kebersihan
genitalia .............................................................
m. Anus : Ada/ atresia ani, Rectal tuse (khusus
hirschprung) ............ ............................................
n. Integumen
Insp : Warna kulit (............................), hidrasi kulit (.........................................),
ptekie (......), Ikterik (......) derajat ................ pada bagian ......................................
..................................................................................................................................
, verniks kaseosa (.......), lanugo (....................), hematoma (....)
pada .................. ...................................., purpura (.....)
pada ............................................................. ................., luka (.....)
pada ........................................................................... dengan karakteristik
luka ...................................................................................... ...................................
.....................................................Udem (....................... .....................................),
diaforesis (.......)
Palpasi: Pitting udem (........................), Suhu kulit teraba .....................................
o. Tanda-tanda vital

Tekanan darah : ....................... Respirasi rate:...................

Nadi :......................... Suhu Tubuh :....................

 Pemeriksaan refleks bayi baru lahir

Eyeblink Refleks : .............. Refleks Babinski: ..............

Refleks Grabella : .............. Refleks Plantar : ..............
Refleks Rooting : .............. Refleks Stepping: ..............
Refleks Sucking : .............. Refleks Peres : ..............
Refleks Swallowing : .............. Refleks Crawling: ..............
Refleks Ekstrusi : .............. Refleks Morro : ..............
Refleks Palmar Grasping: ..............

STIKES SYEDZA SAINTIKA PADANG 14

 K. Keadaan Psikososial Anak dan Orang tua/ Care giver
 Kemampuan orang tua/ care giver untuk bekerja sama dalam setiap asuhan
keperawatan.......................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
 Bagaimana ansietas anak saat dirawat/ kunjungan poliklinik (menghambat/ tidak
menghambat tindakan asuhan keperawatan)
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
 Bagaimana ansietas orang tua/ care giver saat anak di rawat/ kunjungan poliklinik
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
L. Kebutuhan Edukasi pada Orang Tua
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

ANALISA DATA

Inisial Pasien : ................................. Umur : .................................

Tanggal : ................................. Diagnosa Medis: .................................
Nomor Register: ................................. Ruang / Kamar : .................................

NO DATA FOKUS MASALAH

PENYEBAB
(SUBJEKTIF DAN OBJEKTIF) KEPERAWATAN

STIKES SYEDZA SAINTIKA PADANG 15

NO DATA FOKUS MASALAH
PENYEBAB
(SUBJEKTIF DAN OBJEKTIF) KEPERAWATAN

STIKES SYEDZA SAINTIKA PADANG 16

III. DIAGNOSA KEPERAWATAN

NO DAFTAR DIAGNOSA KEPERAWATAN

(BERDASARKAN PRIORITAS MASALAH)

STIKES SYEDZA SAINTIKA PADANG 17

 IV. RENCANA KEPERAWATAN

Inisial Pasien : ................................. Nomor Register : .................................

Umur : ................................. Tanggal/ Shift : .................................
Diagnosa Medis : ................................. Ruang / Kamar : .................................

No TUJUAN DAN KRITERIA HASIL INTERVENSI AKTIVITAS NIC

MASALAH KEPERAWATAN
(NOC) NIC

No TUJUAN DAN KRITERIA HASIL INTERVENSI AKTIVITAS NIC

MASALAH KEPERAWATAN
(NOC) NIC
 V. IMPLEMENTASI

CATATAN PERKEMBANGAN ASUHAN KEPERAWATAN

Inisial Pasien : ...............................

Ruang / Kamar : ...............................

TANGGAL DIAGNOSA
IMPLEMENTASI KEPERAWATAN EVALUASI
KEPERAWATAN

TANGGAL DIAGNOSA
IMPLEMENTASI KEPERAWATAN EVALUASI
KEPERAWATAN