B. Orang tua
1. Ayah
a. Nama : …………………………………(kandung/tiri)
b. Umur : …………………………………………………
c. Pekerjaan : …………………………………………………
d. Pendidikan : …………………………………………………
e. Agama : ………………………………………………..
f. Alamat : …………………………………………………
2. Ibu
a. Nama : …………………………………(kandung/tiri)
b. Umur : …………………………………………………
c. Pekerjaan : …………………………………………………
d. Pendidikan : …………………………………………………
e. Agama : …………………………………………………
f. Alamat : …………………………………………………
II. GENOGRAM
III. ALASAN DIRAWAT
a) Keluhan Utama :
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b) Riwayat Penyakit :
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4. Suara nafas :
Anak-anak
Keadaan sebelum sakit (nafsu makan, berapa kali sehari, jenis makanan pokok,
jenis lauk, jenis sayuran, jenis buah, makanan pantang, kebiasaan makan
termasuk cara menyajikan makanan, jenis makanan selingan, kebiasaan jajan)
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Keaadan saat sakit bagaimana …………………………………………
C. Eliminasi (BAB/BAK)
Bias memberitahu / tidak, melakukan sendiri/ditolong, tempat bab/bak,
frekuensi, warna, bau, konsistensi, kelainan
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D. Aktifitas
Permainan
Suka bermain (ya/tidak), permainan yang disukai,
Mainan yang dimiliki, teman bermain
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E. Rekreasi
Pernah / jarang / kadang-kadang, jenis rekreasi
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G. Kebersihan diri
Mandi :
Mandi sendiri/dibantu oleh ………………………………………..
Di …………………………………………………………………..
Memakai sabun/tidak ………………………………………………
Dikeringkan dengan handuk/tidak ………………………………….
Gosok gigi : (dikerjakan sendiri/ditolong, menggunakan pasta gigi, waktu
menggosok gigi)
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H. Pengaturan suhu
tubuh…………………………………………………………………………
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I. Rasa nyaman
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J. Rasa aman
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L. Prestasi
Kepandaian anak sekarang, prestasi yang dimiliki
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L. Leher:
Pembesaran kelenjar/pembuluh darah, kaku kuduk, pergerakkan leher
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M. Thoraks:
Bentuk dada, irama pernafasan, tarikan otot bantu pernafasan, adanya suara
nafas ……..
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N. Jantung : (bunyi, pembesaran)
O. Persarafan : (seflek fisiologis, reflek patologis)
P. Abdomen :
Bentuk, pembesaran organ, keadaan pusat, teraba skibala, massa, nyeri pada
perabaan, distensia, hernia, peristaltic
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Q. Ekstremitas :
Kelainan bentuk, pergerakan, reflek lutut, adanya udem, keadaan unjung
ekstremitas, hal-hal lain
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R. Alat kelamin : ……………………………………………………………….
S. Anus : …………………………………………………………………………..
T. Antropometri (ukuran pertumbuhan)
1. BB = kg
2. TB = cm
3. Lingkar kepala = cm
4. Lingkar dada = cm
5. Lingkar lengan = cm
U. Gejala kardinal :
1. Suhu =
2. Nadi =
3. Pernafasan =
4. Tekanan darah =
ANALISIS DATA
TGL/JAM DATA STANDAR INTERPRETASI/PENYEBAB MASALAH
FOKUS NORMAL
DO:
DS:
DO:
DS:
DO:
DS:
ANALISIS MASALAH
DIAGNOSA KEPERAWATAN
No Tanggal muncul Diagnosa Keperawatan
XV TINDAKAN KEPERAWATAN