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 :
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 Internatal :
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Postnatal :
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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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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:

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

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 Kognitif dan bahasa : …………………………………......................
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Motorik kasar : ……………………………………...................

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Data Tambahan
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Masalah keperawatan:
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PEMERIKSAAN PENUNJANG:
Terapi
Tanggal Terapi :
Nama Cara
No Dosis Golongan Indikasi Kontra Indikasi
Terapi Pemberian

Pemeriksaan Penunjang :
Laboratorium
USG

EKG
Rontsen

EEG

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..............................................................................................................................................................
2..............................................................................................................................................................

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..............................................................................................................................................................
2..............................................................................................................................................................
3..............................................................................................................................................................

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..............................................................................................................................................................
3..............................................................................................................................................................

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..............................................................................................................................................................
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..............................................................................................................................................................
2..............................................................................................................................................................
3..............................................................................................................................................................

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

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 kelamin Riwayat persalinan Riwayat imunisasi

anak

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

PEMERIKSAAN PENUNJANG
ANALISA DATA
 DATA KLIEN Etiologi Masalah Keperawatan

Ds: Patoflow

Do :

PRIORITAS MASALAH KEPERAWATAN

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