SEKOLAH TINGGI ILMU KESEHATAN WIYATA HUSADA SAMARINDA

FORMAT PENGKAJIAN ANAK

Nama Mahasiswa : ………………………………………………..

Tempat Praktek : ………………………………………………..

Tanggal Praktek : ………………………………………………..

I. Pengkajian
A. Identitas Data
1. Nama : ……………………………………………….
2. Tempat/Tgl lahir : ……………………………………………….
3. Usia : ……………………………………………….
4. Nama Ayah/Ibu : ……………………………………………….
5. Pekerjaan Ayah : ……………………………………………….
6. Pekerjaan ibu : ……………………………………………….
7. Pendidikan Ayah : ……………………………………………….
8. Pendidikan Ibu : ……………………………………………….
9. Agama : ……………………………………………….
10. Suku/Bangsa : ……………………………………………….
11. Alamat : ……………………………………………….

B. Keluhan Utama
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
C. Riwayat Keluhan Saat ini
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
D. Riwayat Kesehatan Masa Lalu
1. Prenatal
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
2. Intranatal
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
3. Postnatal
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................

E. Riwayat Masa Lalu

1. Penyakit waktu kecil
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
2. Pernah di rawat di RS
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
3. Obat-obatan yang digunakan
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
4. Tindakan (operasi)
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
 5. Alergi
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
6. Kecelakaan
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
7. Imunisasi
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................

F. Riwayat Pertumbuhan dan perkembangan

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

G. Riwayat Sosial
1. Yang mengasuh : …………………………………………………………………………………………………………………...
2. Hubungan dengan anggota keluarga : …………………………………………………………………………………..
3. Hubungan dengan teman sebaya : …………………………………………………………………………………………

H. Riwayat Keluarga
1. Sosial ekonomi
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
2. Lingkungan rumah
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
3. Penyakit keluarga
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
4. Genogram
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
I. Pengkajian Tingkat perkembangan saat ini
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................

J. Pengkajian Pola Kesehatan Saat ini

1. Pemeliharaan dan persepsi terhadap kesehatan
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
2. Nutrisi
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
3. Cairan
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
4. Aktivitas
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
5. Tidur dan istirahat
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
 6. Eliminasi
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
7. Pola hubungan
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
8. Koping atau temperamen dan disiplin yang di terapkan
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
9. Kognitif dan persepsi
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
10. Konsep diri
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
11. Seksual dan menstruasi
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
12. Nilai
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................

K. Pemeriksaan Fisik
1. Keadaan umum
.........................................................................................................................................................................................
.........................................................................................................................................................................................
 Tanda-tanda vital :

TD:.........................RR......................... Nadi........................Suhu........................BB/TB......................................
Lingkar Kepala..............................Lingkar lengan atas...................................
 Skala Nyeri :

 Resiko Jatuh :
Skala Humpty Dumpty

Parameter Kriteria Nilai Skor

< 3 tahun
Usia 3-7 tahun
7-13 tahun
≥ 13 tahun
Jenis Kelamin Laki-Laki
Perempuan
Diagnosis Diagnosis neurologi
Perubahan oksigenasi (diagnosis respiratorik, dehidrasi,
anemia, sinkop, pusing)
Gangguan Perilaku/Psikiatri
Diagnosis lainnya
Gangguan Tidak menyadari keterbatasan dirinya
Kognitif Lupa akan adanya keterbatasan
Orientasi baik terhadap diri sendiri
Faktor Riwayat jatuh/bayi diletakkan ditempat tidur dewasa
lingkungan Menggunakan alat bantu/diletakkan dalam tempat tidur
bayi
Pasien diletakkan di tempat tidur
Area di luar rumah sakit
Pembedahan/se Dalam 24 jam
dasi/anastesi Dalam 48 jam
>48 jam atau tidak menjalani
pembedahan/sedasi/anastesi
Penggunaan Penggunaan multiple : sedative, obat hypnosis,
medika mentosa barbiturate, fenotiazin, antidepresan, pencahar, diuretic,
narkose
Penggunaan salah satu obat diatas
Penggunaan medikasi lainnya/tidak ada medikasi
Jumlah skor humpty dumpty
 Skor 7-11 : resiko rendah

 Skor ≥ 12 : resiko tinggi

2. Kulit
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
3. Kepala
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
4. Mata
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
5. Telinga
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
6. Hidung
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
7. Mulut
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
8. Leher
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
9. Dada
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
10. Paru
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
 11. Jantung
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
12. Abdomen
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
13. Genetalia
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
14. Anus dan rectum
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
15. Muskuloskeletal
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
16. Neurologi
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................

L. Pemeriksaan Diagnostik lainnya

1. Pemeriksaan Laboratorium
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
 …………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
2. Pemeriksaan Rontgen
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
3. Dan lain-lain
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………

M. Program terapi dan Cairan

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

N. Informasi lain
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................

Samarinda, ................... 201

Perawat

(...............................................)
II. Analisa Data

No Data Penunjang Kemungkinan Penyebab Masalah

III. Diagnosa Keperawatan
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
....................................................................................................................................................................................................
 RENCANA KEPERAWATAN

DIAGNOSA KEPERAWATAN
NO TUJUAN (NOC) INTERVENSI (NIC) RASIONAL
/MASALAH KOLABORASI
 Catatan Perkembangan
Nama Klien : Umur :
No RM : Ruang :

Hari/Tgl No. Dx Implementasi Evaluasi Paraf

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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