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YAYASAN MARANATHA KUPANG

SEKOLAH TINGGI ILMU KESEHATAN MARANATHA KUPANG


PROGRAM PROFESI NERS
JL. KAMP. BAJAWA NASIPANAF BAUMATA BARAT – KAB. KUPANG
FORMAT PENGKAJIAN
KEPERAWATAN ANAK

Nama Mahasiswa : ...........................................


NIM : ...........................................
Tempat Praktek : ...........................................
Tanggal Pengkajian : ...........................................
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I. IDENTITAS KLIEN NO. MR :
Nama Klien (inisial) : An. Nama orangtua :
Jenis Kelamin : L/ P Alamat :
Tanggal lahir : Diagnosa Medis :
Tanggalmasuk :
Jam :
II. KELUHAN UTAMA :

Riwayat Keluhan Utama :

Keadaan umum :  sakit ringan  sakit sedang  sakit berat GCS : ................................
Kesadaran :  CM  Apatis  Sopor  Somnolen  Coma
Tanda Vital
Suhu :……..C Nadi : ............... x/mnt
Pernapasan :............. x/mt Tekanan darah : / mmHg

III. RIWAYAT KEHAMILAN DAN KELAHIRAN :


 Prenatal
 Tempat pemeriksaan kehamilan:......................................................................................
Frekuensi pemeriksaan kehamilan :
......................................................................................................
Sakit yang diderita/ keluhan :
......................................................................................................

 Intranatal
Tempat persalinan : ....................................................

Tenaga Penolong :......................................................

Jenis Persalinan :  spontan  SC  Forcep  Induksi

Usia kehamilan :…………..minggu Berat badan lahir :………gram

Apgar score : ........................................ Panjang badan lahir : ............cm

Menangis :  ya  tidak, Jaundice :  ya  tidak

 Postnatal
Lama mendapat ASI : ............................................................

ASI eksklusif :  ya  tidak

Usia mendapatkan MP-ASI : ..............................................................

IV. RIWAYAT MASA LAMPAU


1. Penyakit waktu kecil :
..............................................................................................................
2. Pernah dirawat di RS :
..............................................................................................................
3. Obat-obatan yang digunakan :
.............................................................................................................
4. Tindakan (operasi) :
.............................................................................................................
5. Alergi :  tidak  ya, sebutkan……………………………………
6. Kecelakaan :.................................................................
7. Imunisasi dasar : Hepatitis :  I  II  III BCG : 
DPT : I  II  III Campak : 
Polio : I  II  III  IV

V. RIWAYAT KELUARGA (DISERTAI GENORAM)


VI. RIWAYAT SOSIAL
1. Orang yang mengasuh : .............................................................................................
2. Hubungan dengan anggota keluarga :
............................................................................................
3. Hubungan anak dengan teman sebaya :
............................................................................................
4. Pembawaan secara umum :
............................................................................................
5. Lingkungan rumah : .............................................................................................

VII. KEBUTUHAN DASAR


1. Nutrisi
Makanan yang disukai/ tidak disukai :......................................................

Selera : .....................................................................................................

Alat makan yang digunakan : .................................................................

Pola makan/ jam : .............................................................................

2. Istirahat dan tidur


Pola tidur : .......................................................................................

Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa saat tidur, dll)
:.............................................................................................

Jam tidur siang dan lama tidur : ..................................................................

Jam tidur malam dan lama tidur : ..................................................................

3. Personal hygiene
Mandi : ............................... Keramas : .......................

Sikat gigi : ................................. Gunting kuku : ...................

4. Aktivitas bermain :
......................................................................................................................
5. Eliminasi (urine dan bowel) :
......................................................................................................................

VIII. KEADAAN KESEHATAN SAAT INI


1. Tindakan operasi : ................................................................................
2. Status nutrisi : ................................................................................
3. Status cairan : ................................................................................
4. Obat yang didapat :
Nama KontraIndikasi
NO Indikasi
Obat/Dosis/Cara
5. Aktivitas : ................................................................................
6. Pemeriksaan Penunjang, meliputi :
a. Laboratorium (tgl/jam) :

b. Radiologi ( tgl/jam) :

7. Dampak hospitalisasi :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
..............................................

IX. PEMERIKSAAN FISIK


1. Keadaan umum :
......................................................................................................................
.......................................................................................................................

2. Tinggi Badan : .................cm BB saat ini : ................Kg


BB seb sakit : .................Kg BB ideal : ......Kg
Status Gizi : Kurang/normal/Gemuk
3. Kepala :
Lingkar kepala : ...................cm Hidrosefalus :  ya  tidak

Ubun-ubun anterior : .................................................................................

Ubun ubun posterior : .................................................................................

4. Leher : kaku kuduk :  ya  tidak


Pembesaran limfe :  ya  tidak

5. Mata :
Konjuctiva :  anemis  merah muda

Sklera :  putih  ikterik  kemerahan


6. Telinga :  bersih  kotor
Simetris :  ya  tidak
Gangguan pendengaran :  ya  tidak
Sekresi/ serumen :  ya  tidak Nyeri :  ya  tidak
7. Hidung : Hidung : sekret  ya  tidak
8. Mulut : Mukosa :  lembab  kering  kotor  sariawan
Lidah :  lembab  kering  kotor  jamur
Gigi :  bersih  kotor  karies
9. Dada :
.......................................................................................................................
Lingkar dada : ........... cm

10. Jantung :
.......................................................................................................................
11. Paru – paru :
.......................................................................................................................
12. Abdomen :  lembek  kembung  tegang
Lingkar Perut ………..cm
Bising usus :  ya  tidak Frekuensi :…………..x/mnt
Mual :  ya  tidak
Muntah :  tdk  ya, frekuensi …………x
13. Genitalia :
Perempuan : Vagina :  bersih  kotor
Menstruasi :  ya  tidak
Pemasangan kateter :  ya  tidak
Laki-laki : Preputium :  bersih  tidak
Phimosis :  bersih  tidak
Hipospadia :  ya  tidak
Skrotum : Testis kanan/kiri  ya  tidak
Pemasangan kateter :  ya  tidak
Sirkumsisi :  ya  tidak
14. Anus :
..................................................................................................................
15. Ekstremitas :
Pergerakan sendi : bebas  terbatas  Lain-lain …….
Berjalan :  normal  tidak normal
Kekuatan otot :  normal  tidak normal
Fraktur :  ya  tidak
Ketrampilan motorik :  baik  tidak

X. PEMERIKSAAN TINGKAT PERKEMBANGAN (Gunakan KPSP)


1) Sosialisasi dan Kemandirian
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
2) Motorik kasar
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
3) Motorik halus
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
4) Kemampuan Bicara dan Bahasa
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................

Kesimpulan :  Sesuai usia  Meragukan  Penyimpangan


Intervensi yang diberikan :

1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________
4. __________________________________________________________________

XI. INFORMASI LAIN

1. Pengetahuan orang tua :


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.......................................................................................................................
.......................................................................................................................
2. Persepsi orang tua terhadap penyakit anaknya :
.......................................................................................................................
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XII. Analisa Data

No Data Klien Etiologi Masalah Keperawatan


1. DS :

DO :

2.

XIII. Prioritas Masalah

1.
2.
3.
4.
5.

Kupang, ……………………….
Yang Mengkaji

(..................................................................)
Rencana Keperawatan

Diagnosa
No Keperawatan NOC NIC

CATATAN PERKEMBANGAN
ASUHAN KEPERAWATAN

Nama Pasien :
Umur :
Jenis Kelamin :
Diagnosa Medis :
No RM :
Hari/ Tanggal :
No Jam Diagnosa Implementasi Evaluasi
Keperawatan Keperawatan ( SOAP)