FORMAT PENGKAJIAN KEPERAWATAN ANAK

A. Identitas
Nama :
Umur :
Nama ayah :
Nama ibu :
Pekerjaan ayah :
Pekerjaan ibu :
Alamat :
Suku :
Agama :
Pendidikan :

B. Keluhan Utama
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C. Riwayat Kehamilan dan Kelahiran

1. Prenatal
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2. Natal
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3. Postnatal
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D. Riwayat Kesehatan Masa Lampau

1. Penyakit waktu kecil
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2. Riwayat dirawat di rumah sakit
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3. Obat-obatan yang digunakan
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4. Tindakan (operasi)
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5. Alergi
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6. Kecelakaan
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7. Imunisasi
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E. Riwayat Keluarga
Genogram

F. Riwayat sosial
1. Yang mengasuh
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2. Hubungan dengan anggota keluarga

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3. Hubungan dengan teman sebaya

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4. Pembawaan secara umum

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5. Lingkungan rumah
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G. Kebutuhan Dasar
1. Makanan
a. Makanan yang disukai
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b. Selera
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c. Alat makan yang dipakai

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d. Pola makan/ jam

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2. Pola tidur
a. Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang
dibawa tidur)
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b. Tidur siang
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3. Kebersihan diri (mandi)

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4. Aktivitas bermain
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5. Eliminasi
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H. Keadaan Kesehatan Saat Ini

1. Diagnosa medis :_______________________________________
2. Tindakan operasi :_______________________________________
3. Status cairan :
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4. Status nutrisi :
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5. Obat-obatan :
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6. Aktivitas :
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____________________________________________________________
7. Hasil laboratorium :
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8. Foto rontgen :
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9. Hasil pemeriksaan penunjang lainnya :
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I. Pemeriksaan Fisik
1. Keadaan umum : _________________________________________
2. Tanda vital
a. RR : ___________________x/menit (regular/ irregular)
b. HR : ___________________x/menit (regular/ irregular)
c. TD : ___________________mmHg
d. Suhu : ___________________oC
3. TB / BB : __________________________________________
4. Lingkar kepala : _________________________________________
5. Kepala : _________________________________________
6. Mata : _________________________________________
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7. Leher : _________________________________________
8. Telinga : _________________________________________
9. Hidung : _________________________________________
10. Mulut : _________________________________________
11. Dada : _________________________________________
12. Paru-paru : _________________________________________
13. Jantung : _________________________________________
14. Perut : _________________________________________
15. Punggung : _________________________________________
16. Genetalia : _________________________________________
17. Ekstremitas atas : _________________________________________
18. Ekstremitas bawah : _________________________________________

J. Pemeriksaan Tingkat Perkembangan

1. Kemandirian dan sosialisasi
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2. Motorik halus
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3. Motorik kasar
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4. Kemampuan bicara dan bahasa

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