FORMAT PENGKAJIAN ANAK

Nama Mahasiswa : ………………………………

Tempat Praktek : ………………………………
Tanggal Praktek : ………………………………

Pengkajian Dilakukan Tanggal................jam................WIB

I. IDENTITAS
Inisial Nama : …………………... Alamat : …………
Tempat/tgl.lahir : …………………... Agama : …………
Usia : …………………... Suku Bangsa : …………
Nama Ayah/Ibu : …………………... Pendidikan ayah: …………
Pekerjaan Ayah : …………………... Pendidikan ibu : …………
Pekerjaan Ibu : …………………...

II. RIWAYAT KEPERAWATAN

a. Keluhan Utama (saat masuk RS)
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b. Keluhan utama (saat pengkajian)
............................................................................................................................................
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c. Riwayat Perjalanan Penyakit
............................................................................................................................................
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d. Riwayat Kehamilan dan Kelahiran Anak
 Prenatal :
……………………………………………………………........................................

Internatal :
……………………………………………………………........................................

Postnatal :
……………………………………………………………..........................................

e. Riwayat Masa Lampau

1.Penyakit waktu kecil :
……………………………………..................,,,,,,,,,,,,,,,,,,,
2.Pernah dirawat di RS :
…………………………………….......................................
3.Obat-obatan yang digunakan :
…………………………………….......................................
4.Tindakan (operasi) :
……………………………………………..........................
5.Alergi :……………………………………………..........................
6.Kecelakaan : ……………………………………………..........................
7.Imunisasi : …………………………………………….........................
 f. Riwayat Keluarga
Genogram

g. Riwayat Sosial
Yang mengasuh : …………………………………….....................
Hubungan dengan anggota keluarga :………………….............................
Hubungan dengan teman sebaya : …………………….........................
Pembawaan secara umum : …………………………………….....................
Lingkungan rumah : …………………………………….....................

IV. KEADAAN KESEHATAN SAAT INI

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V. PENGKAJIAN FISIK (12 DOMAIN NANDA)

1. PROMOSI KESEHATAN (KESADARAN & MANAJEMEN KESEHATAN)
................................................................................................................
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Masalah keperawatan:
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2. NUTRISI (MAKAN, PENCERNAAN, ABSORPSI, METABOLISME &
HIDRASI)
a. Mulut
Trismus ( ), Halitosis ( )
Bibir: lembab( ), pucat( ), sianosis( ), labio/palatoskizis( ),
stomatitis( )
Gusi: ( ), plak putih( ), lesi( )
Gigi: Normal( ), Ompong( ), Caries( ), Jumlah gigi:...................
Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
b. Leher
Kaku Kuduk ( ) Simetris( ), Benjolan ( ) Tonsil ( )
Kelenjar Tiroid : normal ( ), pembesaran ( )
Tenggorok : kesulitan menelan ( ),
dll..................................................................................................

Kebutuhan Nutrisi dan Cairan

BB sebelum sakit: kg BB sakit: kg
Makanan yang disukai:..........................
Selera makan:...........................
Alat makan yang digunakan:........................
Pola makan( x/ hari):......................
Porsi makan yang dihabiskan:............................
Pola Minum .............................gelas/hari) jenis air
minum:.....................................................
c. Abdomen
Inspeksi : Bentuk: simetris( ), tidak simetris( ), kembung( ),
asites( ),
 Palpasi : massa ( ), nyeri ( )
Kuadran I :
Kuadran II :
Kuadran III :
Kuadran IV :
Auskultasi : bising usus........................x/mnt
Perkusi : Timpani ( ), redup ( )
Data Tambahan :
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Masalah keperawatan:
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3. ELIMINASI & PERTUKARAN (FUNGSI URINARIUS,

GASTROINTESTINAL & PERNAPASAN)
Pola Eliminasi
BAK:
Warna:
Konsistensi:
Frekuensi: x/ hari
Urine Output : cc
Penggunaan Kateter:.............................................................................................
Vesika Urinaria: Membesar .....................Nyeri tekan............................
Gangguan; Anuaria ( ), Oliguria ( ), Retensi Uria ( ), nokturia ( ),
Inkontinensia Urin ( ), Poliuria ( ), Dysuria ( )
 Jelaskan:...............................................................................................................

BAB : warna........................................Frekuensi................................x/hari
Konsisitensi:.................................... lendir ( ), darah ( ), ampas ( )
Konstipasi ( )

Jalan nafas: Sputum ( ), warna sputum ( )

konsisitensi:........................................
Batuk ( ) frekuensi:..............................

Dada
Bentuk: Simetris ( ), Barrel chest/dada tong( ), pigeon chest/dada
burung ( ) benjolan ( ), dll………………..

Paru-paru:
Inspeksi: RR………x/ min,
Palpasi: Normal ( ), ekspansi pernafasan( ), taktil fremitus( )
Perkusi: Normal/ Sonor( ), redup/pekak( ), hiper sonor( )
Auskultasi: irama( ), teratur( ),
Suara nafas: vesicular( ), bronkial( ), Amforik ( ), Cog Wheel
Breath Sound ( ) metamorphosing breath sound ( )
Suara Tambahan: Ronki ( ), pleural friction( )
Data Tambahan :
...............................................................................................................
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 ...............................................................................................................
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Masalah keperawatan:
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4. AKTIVITAS / ISTIRAHAT (ISTIRAHAT, AKTIVITAS,

KESEIMBANGAN ENERGI, RESPON KARDIOVASKULAR /
PULMONAL & PERAWATAN DIRI)
Jantung
Inspeksi: ictus cordis/denyut apeks( ), normal( ) melebar( )
Palpasi: kardiomegali( )
Perkusi: redup( ), pekak( )
Auskultasi: HR...............x/mnt. Aritmia( ),Disritmia( ) , Murmur ( )

Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang

dibawa saat tidur, dll):
Kebiasaan Tidur siang:......................................jam/hari

Skala Aktivitas:

Kemampuan 0 1 2 3 4
perawatan diri
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di
tempat tidur
Berpindah
 Ambulasi/ROM
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan
alat, 4: tergantung total

Personal hygine :
Mandi:...................x/hari
Sikat gigi :........................................x/hari
Ganti Pakaian :..................................x/hari
Memotong kuku:...............................x/hari
Data Tambahan :
...............................................................................................................
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Masalah keperawatan:
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5. PERSEPSI / KOGNISI (PERHATIAN, ORIENTASI, SENSASI PERSEPSI,

KOGNISI & KOMUNIKASI)
a. Kesan Umum
Tampak Sakit: ringan ( ), sedang ( ), berat ( ), pucat ( ), sesak (
), kejang ( )
b. Kepala
Bentuk:........................ Hematoma( ), Luka( )
Fontanel: cekung ( ), Datar ( ), Keras ( ), Lunak ( )
Rambut: warna...............mudah dicabut ( ), ketombe( ), kutu( )
 c. Mata
Mata: jernih( ), mengalir, kemerahan( ), sekret( )
Visus: 6/6( ), 6/300( ), 6/ tak terhingga( ),
Pupil: Isokor( ), anisokor( ), miosis( ), midriasis( ),
reaksi terhadap cahaya: kanan Positif( ), negatif( ), kiri negatif(
) positif( ),
alat bantu: kacamata( ), Softlens( )
Conjungtiva: merah jambu( ), anemis( )
Sklera: Putih( ), Ikterik( )

d. Telinga
Simetri( ), sekret( ), radang( ), Pendengaran: ( ), kurang( ),
tuli( )
e. Hidung : Simetris( ), pilek( ), epistaksis( )
f. Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
Data Tambahan :
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Masalah keperawatan:
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6. PERSEPSI DIRI (KONSEP DIRI, HARGA DIRI,& CITRA TUBUH)

Perasaaan klien terhadap penyakit yang
didieritanya.............................................................................
Persepsi klien terhadap
dirinya.........................................................................................................................
Konsep
diri..............................................................................................................................................
......................
Tingkat
kecemasan..............................................................................................................................
......................
CitraDiri/Bodyimage:........................................................................................................
......................................
Data Tambahan :
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Masalah keperawatan:
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7. HUBUNGAN PERAN (PERAN PEMBERI ASUHAN, HUBUNGAN

KELUARGA & PERFORMA PERAN)
Masalah sosial yang penting:
Hubungan orang tua dan bayi:
Orang terdekat yang dapat dihubungi:
Orang tua berespon terhadap penyakit: ya ( ) tidak( )
 Respon:
Orang tua berespon terhadap hospitalisasi: ya ( ) tidak ( )
Data Tambahan
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Masalah keperawatan:
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8. SEKSUALITAS (IDENTITAS, FUNGSI SEKSUALITAS & REPRODUKSI)

Genitalia dan Anus
Laki-laki
Penis: normal/ada ( ), Abnormal…………………,
Scrotum dan testis: normal( ), hernia( ), hidrokel( )
Anus ; normal/ada ( ), atresia ani( )
Perempuan
Vagina: sekret( ), warna( )
Anus: normal/ada ( ), atresia ani( )
Data Tambahan
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Masalah keperawatan:
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9. KOPING / TOLERANSI STRESS (RESPONS PASCATRAUMA, RESPON
KOPING & STRES NEUROBIHAVIOUR)
GCS :.......
E:........................................................................................
V: .......................................................................................
M:.......................................................................................
Reflek Patologis :
Babinsky ...............................................................................................
Kernig ...................................................................................................
Brudzinsky.............................................................................................
Reflek Fisiologis:
Biceps.................................................................................................................
Triceps...............................................................................................................
Patella........................................................................
Data Tambahan
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Masalah keperawatan:
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10. PRINSIP HIDUP (NILAI, KEYAKINAN & KESELARASAN /

KEYAKINAN)
Budaya :
Spritual / Religius :
Harapan :
 Psikososial :
Data Tambahan
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Masalah keperawatan:
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11. KEAMANAN / PERLINDUNGAN (INFEKSI, CEDERA FISIK,

KEKERASAN, BAHAYA LINGKUNGAN, PROSES
PERTAHANAN, & TERMOREGULASI)
Tingkat Kesadaran : Composmentis ( ), Apatis ( ), Somnolen ( ),
Sopor ( ),Soporocoma ( ) Coma ( )
TTV : Suhu.............O C, Nadi........x/min, TD...............mmHg,
RR..........x/min
Warna kulit :
Sianosis ( ), I kterus ( ), eritematosus rash ( ), discoid lupus ( ),
oedema ( ),
Bula ( ), Ganggren ( ), nekrotik jaringan ( ), Hiperpigmentasi ( )
Echimosis ( ), Petekie ( )
Turgor Kulit: elastis ( ), tidak elastis ( )
 Data Tambahan
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Masalah keperawatan:
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12. KENYAMANAN (FISIK, LINGKUNGAN & SOSIAL)

Nyeri : Ya ( ) Tidak ( )
Jika ya, Pengkajian nyeri :
P (Provokatif/paliatif)
Q( Quality)
R(Regio)
S(Scale)
T(Time)
Data Tambahan
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Masalah keperawatan:
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13. PERTUMBUHAN / PERKEMBANGAN
PEMERIKSAAN TINGKAT PERKEMBANGAN (DDST/KPSP jika
kurang dari 6 tahun)
Kemandirian dan bergaul : ……………………………………..................
…………………………………….......,..........

Motorik Halus : ……………………………….........................

………………………………...........................

Kognitif dan bahasa : …………………………………......................

……………………………………....................

Motorik kasar : ……………………………………...................

……………………………………....................

Data Tambahan
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Masalah keperawatan:
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PEMERIKSAAN PENUNJANG:
Terapi
Tanggal Terapi :

Nama Cara Kontra

No Dosis Golongan Indikasi
Terapi Pemberian Indikasi

Pemeriksaan Penunjang :
Laboratorium ( Tanggal Pemeriksaan )
USG ( Tanggal Pemeriksaan )
EKG ( Tanggal Pemeriksaan )
Rontsen ( Tanggal Pemeriksaan )
EEG ( Tanggal Pemeriksaan )
Dll.....

FORMAT PENGKAJIAN NEONATUS (NICU)

Nama Mahasiswa : ………………………………
Tempat Praktek : ………………………………
Tanggal Praktek : ………………………………

Pengkajian Dilakukan Tanggal................jam................WIB

I. IDENTITAS
Inisial Nama : …………………... Alamat : …………
Tempat/tgl.lahir : …………………... Agama : …………
Usia : …………………... Suku Bangsa : …………
Nama Ayah/Ibu : …………………... Pendidikan ayah: …………
Pekerjaan Ayah : …………………... Pendidikan ibu : …………
Pekerjaan Ibu : …………………...

Berat bayi :
Panjang Badan :

Apgar ScorE :

Usia Gestasi :
Berat Badan : Panjang Badan :
Indikasi persalinan :

Tidak ada ( ) Ada ( )

Aspirasi mekonium :

Denyut jantung janin abnormal ( )

Prolaps tali pusat/lilitan tali pusat ( )

Ketuban pecah dini ( ); beberapa jam :
Berat Ibu
Usia Gravida Partus Abortus

Persalinan:
Pervaginam ( )
Sectio caesarea ( ); Alasan :
Komplikasi kehamilan:

 Tidak ada ( ) Ada ( )

 Perawatan antenatal ( )
 Ruptur plasenta / plasenta previa ( )
 Pre eklampsia / toxcemia ( )
 Suspect sepsis ( )
 Persalinan premature/post matur ( )
 Masalah lain :

A. Pemeriksaan Fisik
Intruksi: Beri tanda cek () pada istilah yang tepat/ sesuai dengan data-
data di bawah ini. Gambarkan semua temuan abnormal secara objektif,
gunakan kolom data tambahan bila perlu.

SISTEM PERSEPSI SENSORI

1. Kepala
a. Fontanel anterior Lunak ( ) Tegas ( )Datar ( )
Menonjol ( )
Cekung ( )
b. Sutura sagitalis:Tepat ( ) Terpisah ( ) Menjauh ( )
Tumpang tindih ( )
c. Gambaran wajah Simetris ( ) Asimetris ( )
d. Molding ( ) Caput succedaneum ( ) Cephalhematoma ( )
 2. Mata
Bersih ( ) Sekresi ( )
Jarak interkantus Sklera: Putih ( ) ikterik ( )

5. Bibir
a. Bibir : normal ( ) sumbing ( )
b. Sumbing langit-langit/palatum ( )

6.Telinga, Hidung, Tenggorok

a. Telinga: Normal ( )Abnormal ( ) Sekret( )
b. Hidung: Simetris ( )Asimetris ( ) Sekret ( ) Nafas cuping
hidung ( )
c. Tenggorok: Tonsil( ), radang( )

Masalah Keperawatan:
1.....................................................................................................................................................
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2.....................................................................................................................................................
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3.....................................................................................................................................................
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SISTEM RESPIRASI

7. Toraks
Simetris ( ) Retraksi dada ( ) Klavikula normal ( )

Paru-paru
a. Suara nafas kanan kiri sama ( ) Tidak sama ( )
b. Suara nafas bersih ( ) ronchi ( ) sekresi ( )
wheezing ( ) vesikuler ( ) tidak spontan ( )
c. Respirasi spontan ( ) Tidak spontan ( )

Alat bantu nafas:

( ) Nasal kanul
( ) O2 / incubator
Konsentrasi O2 : ltr/menit
Masalah Keperawatan:
1.....................................................................................................................................................
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2.....................................................................................................................................................
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3.....................................................................................................................................................
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SISTEM KARDIOVASKULER
Jantung
Inspeksi: ictus cordis/denyut apeks( ), normal( ) melebar( )
Palpasi: kardiomegali( )
Perkusi: redup( ), pekak( )
Auskultasi: HR...............x/mnt. Aritmia( ),Disritmia( ) , Murmur ( )
Masalah Keperawatan:
1.....................................................................................................................................................
........................................
2.....................................................................................................................................................
........................................
3.....................................................................................................................................................
........................................

SISTEM PENCERNAAN
Mulut
Trismus ( ), Halitosis ( )
Bibir: lembab( ), pucat( ), sianosis( ), labio/palatoskizis( ),
stomatitis( )
Gusi: ( ), plak putih( ), lesi( )
Gigi: Normal( ), Ompong( ), Caries( ), Jumlah gigi:...................
 Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
Kebutuhan Nutrisi dan Cairan
BB sebelum sakit: kg BB sakit: kg
Makanan yang disukai:..........................
Selera makan:...........................
Alat makan yang digunakan:........................
Pola makan( x/ hari):......................
Porsi makan yang dihabiskan:............................
Pola Minum .............................gelas/hari) jenis air
minum:.....................................................

Abdomen
Inspeksi : Bentuk: simetris( ), tidak simetris( ), kembung( ),
asites( ),
Palpasi : massa ( ), nyeri ( )
Kuadran I :
Kuadran II :
Kuadran III :
Kuadran IV :
Auskultasi : bising usus........................x/mnt
Perkusi : Timpani ( ), redup ( )

BAB : warna........................................Frekuensi................................x/hari
Konsisitensi:.................................... lendir ( ), darah ( ), ampas ( )
Konstipasi ( )
Masalah Keperawatan:
1.....................................................................................................................................................
........................................
2.....................................................................................................................................................
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3.....................................................................................................................................................
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SISTEM REPRODUKSI
Genitalia dan Anus
Laki-laki
Penis: normal/ada ( ), Abnormal…………………,
Scrotum dan testis: normal( ), hernia( ), hidrokel( )
Anus ; normal/ada ( ), atresia ani( )
Perempuan
Vagina: sekret( ), warna( )
Anus: normal/ada ( ), atresia ani( )

Masalah Keperawatan:
1.....................................................................................................................................................
........................................
2.....................................................................................................................................................
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3.....................................................................................................................................................
.......................................

SISTEM MUSKULO SKELETAL

Reflek
Moro :
Mengisap :
Rooting :
 Dan lain-
lain:........................................................................................................................................
................

ROM:

Tonus/aktifitas
a. Aktif ( ) Tenang ( ) Letargi ( ) Kejang ( )
b. Menagis keras ( ) lemah ( ) melengking ( )
Sulit menangis ( )
Ekstremitas
Amelia ( ), Sindaktili ( ), Polidaktili( )
Reflek Patologis :
Babinsky ...............................................................................................
Kernig ...................................................................................................
Brudzinsky.............................................................................................
Reflek Fisiologis:
Biceps.................................................................................................................
Triceps...............................................................................................................
Patella.................................................................................................................
Masalah Keperawatan:
1.....................................................................................................................................................
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2.....................................................................................................................................................
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3.....................................................................................................................................................
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SISTEM INTEGUMEN
Kulit
a. Warna Pink ( )pucat ( ) Jaundice ( )
Sianosis pada kuku ( ) sirkumoral ( )
Periorbital ( ) seluruh tubuh ( )
 b. Kemerahan (rash) ( )
c. Tanda lahir: ( ); sebutkan:
d. Turgor kulit: elastis ( ) tidak elastis ( ) edema ( )
Lanugo ( )
Suhu
a. Lingkungan
Penghangat radian ( ) Pengaturan suhu ( )
Inkubator ( ) Suhu ruang ( ) Boks terbuka ( )

Masalah Keperawatan:
1.....................................................................................................................................................
........................................
2.....................................................................................................................................................
........................................
3.....................................................................................................................................................
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HUBUNGAN PERAN
Struktur keluarga (genogram tiga generasi) :

Budaya :
Suku :
Agama :
Bahasa Utama :
Perencanaan makanan bayi :
Masalah sosial yang penting :
Hubungan orang tua dan bayi :

- Orang terdekat yang dapat dihubungi:

- Orang tua berespon terhadap penyakit: ya ( ) tidak( )
Respon:
- Orang tua berespon terhadap hospitalisasi: ya ( ) tidak ( )
Respon:

- Riwayat anak lain:

Jenis Riwayat Riwayat

kelamin persalinan imunisasi
anak

TERAPI
Nama Cara Golongan Kontra
No Dosis Indikasi
Terapi Pemberian Obat Indikasi

PEMERIKSAAN PENUNJANG
 ANALISA DATA

DATA KLIEN Etiologi Masalah Keperawatan

Ds: PATOFLOW

Do :

PRIORITAS MASALAH KEPERAWATAN

1……………………………………………………….
2……………………………………………………….
3……………………………………………………….

DIAGNOSA KEPERAWATAN
1……………………………………………………….
2……………………………………………………….