FORMAT PENGKAJIAN ANAK UNTUK PASIEN KELOLAAN

I. Identitas Pasien & Keluarga :

Nama Pasien :........................ Nama Ayah/Ibu : .....................

Usia :........................ Usia Ayah/Ibu :......................
Jenis Kelamin :........................ Agama :......................
Anak ke..... dari.... bersaudara........ Alamat : .....................
Tanggal Masuk :........................ Suku bangsa :......................
Tgl Pengkajian :........................ Pendidikan :......................
Diagnosa Medis : .........................Pekerjaan :......................

II. Keluhan Utama :

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

III. Keadaan Sakit Saat Ini (kembangkan PQRST)

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

IV. Riwayat Anak pada Masa

1. Prenatal.............................................................................................
..........................................................................................................
..........................................................................................................
2. Intranatal...........................................................................................
..........................................................................................................
..........................................................................................................
3. Postnatal............................................................................................

V. Riwayat Kesehatan Masa lalu :

1. Riwayat penyakit sebelumnya : ................................................
2. Pernah dirawat di RS : ................................................
3. Obat-obatan yang digunakan : ................................................
4. Tindakan (operasi) : ................................................
5. Alergi : ................................................
6. Kecelakaan : ................................................
7. Imunisasi dasar : ................................................

VI. Riwayat Penyakit Keluarga (disertai Genogram), tuliskan sampai dengan 2 generasi dalam
keluarga
...............................................................................................................
...............................................................................................................
VII. RIWAYAT SOSIAL :
1. Yang mengasuh ............................................................................
2. Hubungan dengan anggota keluarga .............................................
3. Hubungan dengan teman sebaya ..................................................
4. Pembawaan secara umum .............................................................
......................................................................................................
5. Lingkungan rumah........................................................................
......................................................................................................

VIII. KEBUTUHAN DASAR

1. Nutrisi
......................................................................................................
......................................................................................................
......................................................................................................

2. Eliminasi
......................................................................................................
......................................................................................................
......................................................................................................

3. Istirahat tidur
......................................................................................................
......................................................................................................
......................................................................................................
4. Aktifitas
......................................................................................................
......................................................................................................
......................................................................................................

IX. Pemeriksaan Tingkat Pertumbuhan & Perkembangan

1. Pertumbuhan Fisik
......................................................................................................
......................................................................................................
......................................................................................................

2. Perkembangan Motorik Kasar

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

3. Perkembangan Motorik Halus

......................................................................................................
......................................................................................................
......................................................................................................
4. Perkembangan Bahasa
......................................................................................................
......................................................................................................
......................................................................................................
5. Perkembangan Sosial
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
6. Perkembangan Kognitif
......................................................................................................
......................................................................................................
......................................................................................................
Keterangan : untuk anak usia 0-6 tahun mengacu pada format DENVER II atau KPSP dan buatkan
kesimpulan ditiap ranah perkembangan yang telah dicapainya. Untuk anak yang usia
lebih dari 6 tahun menggunakan pendekatan teori pertumbuhan dan perkembangan sosial
yang sesuai usianya. Untuk neonatus perlu dikaji reflek primitif.

X. Tinjauan Sistem :
1. Keadaan umum dan tanda-tanda vital :
KeadaaanUmum :..........................................................................
......................................................................................................
a. TB dan BB : .................. dan.......................................
b. Lingkar kepala :.................................................................
c. Lingkar lengan :.................................................................
d. Suhu :.................................................................
e. Nadi :.................................................................
f. Pernafasan :.................................................................
g. Tekanan darah :.................................................................
2. Pengkajian Kardiovaskuler :
a. Nadi, denyut apeks- frekuensi, irama dan kualitas :................
................................................................................................
Nadi perifer (ada/ tidak ada) : jika ada, frekuensi, irama, kualitas dan perbedaan antar
ekstremitas .............................................................................
 ................................................................................................
b. Pemeriksaan toraks dan hasil auskultasi :
Lingkar dada (toraks) :............................................................
Adanya deformotas :...........................................................
Bunyi jantung :.........................................................
c. Tampilan Umum
Tingkat aktifitas :....................................................................
Perilaku : apatis, gelisah, ketakutan :......................................
Jari tabuh (dubbling) pada tangan dan kaki :...........................
................................................................................................
d. Kulit
Warna :........................................................................
Elastisitas :........................................................................
Suhu tubuh :........................................................................
e. Edema
Periorbital :........................................................................
Ekstremitas :.........................................................................

3. Pengkajian Respitarori
a. Bernafas :
Frekuensi pernafasan, kedalam dan kesemitrisan :..................
................................................................................................
................................................................................................
Pola Nafas: apnea, takipnea :..........................................
Retraksi : .........................................
Pernafasan cuping hidung :..........................................
Posisi yang nyaman : .........................................
b. Hasil Auskultasi toraks
Bunyi nafas :..........................................
Fase Ekspirasi dan inspirasi memanjang :...............................
................................................................................................
................................................................................................
c. Hasil pemeriksaan toraks :
Lingkar dada :.....................................................................
Bentuk dada :.....................................................................

4. Pengkajian Neurologi
a. Tingkat kesadaran (hasil GCS) :................................................
b. Pemeriksaan kepala :
Bentuk kepala :..................................................................
Fontanel :..................................................................
Lingkar kepala (dibawah 2 tahun):..........................................
 c. Reaksi Pupil
Ukuran :..................................................
Reaksi terhadap cahaya :..................................................
d. Aktifitas Kejang
Jenisnya :..................................................................
Lamanya :..................................................................
e. Fungsi sensoris
Reaksi terhadap nyeri :............................................................
................................................................................................
f. Refleks
Refleks tendon dan superficial :..............................................
................................................................................................
Refleks patologis :..................................................................

g. Kemampuan intelektual (tergantung tingkat perkembangan)

Perkembangan menulis & menggambar :................................
................................................................................................
Kemampuan membaca :..........................................................
................................................................................................
5. Pengkajian Gastrointestinal
a. Hidrasi
Turgor Kulit :..........................................................
Membran mukosa :..........................................................
Asupan & haluaran : .........................................................
................................................................................................
b. Abdomen
Nyeri :..........................................................
Kekakuan :..........................................................
Bising usus :..........................................................
Muntah (jumlah, frekuensi dan karakteristik) :
................................................................................................
................................................................................................
 Feses (frekuensi dan karakteristik) :
...............................................................................................
................................................................................................
Kram :..................................................................................
................................................................................................

6. Pengkajian Renal/ Ginjal

a. Fungsi Ginjal :
Nyeri tekan pinggang atau suprapubik:...................................
................................................................................................
Disuria :...............................................................................
................................................................................................
Pola berkemih (lancar/ menetes) ............................................
Adanya acites :..........................................................
Adanya edema pada (skrotum, periorbital, tungkai bawah):
................................................................................................
................................................................................................
b. Karakteristik urine dan urinasi :
Urine tampak bening atau keruh : .................................
Warna : .................................
Bau (amoniak atau aseton) : .................................
Berat Jenis : .................................
Menangis saat berkemih :
c. Genetalia :
Iritasi :..................................................................................
Seklret :..................................................................................
7. Pengkajian Muskuloskeletal
a. Fungsi Motorik Kasar :
Ukuran Otot (adanya atropi/ hipertropi otot) :
................................................................................................
Tonus Otot (spastis, rentang gerak terbatas) :
................................................................................................
................................................................................................
Kekuatan : .......................................................
Gerakan Abnormal :........................................................
b. Fungsi Motorik Halus :
Manipulasi mainan :........................................................
Menggambar :........................................................
c. Kontrol Postur
Mempertahankan posisi tegak :...............................................
 Bergoyang-goyang :.......................................................
d. Persendian
Rentang gerak : ..............................................
Kontraktur : ..............................................
Adanya edema dan nyeri : ..............................................
Tonjolan abnormal :...............................................
e. Tulang Belakang
Lengkung tulang belakang (Scoliosis, kiposis):......................
................................................................................................

8. Pengkajian Hematologi
a. Kulit :
Warna : ..............................................
Adanya ptechea, memar : ..............................................
Perdarahan dari membran mukosa atau dari luka suntikan/ fungsi vena
................................................................................................
b. Abdomen :
Pembesaran hati : ..............................................
Pembesaran Limpa : ..............................................

9. Pengkajian Endokrin
a. Status Hidrasi
Poliuria : ..............................................
Polifagia : ..............................................
Polidipsi : ..............................................
Kulit kering : ..............................................
b. Tampilan Umum
Alam perasaan : ..............................................
Iritabilitas : ..............................................
Sakit Kepala : ..............................................
Gemeteran : ..............................................

10. Obat-obatan Saat ini :

Kontra- Efek
No Nama Obat Dosis Indikasi
indikasi Samping
1
2
3
4
5
6
7
 8

11. Pemeriksaan Laboratorium :

Nilai Nilai saat
No Jenis pemeriksaan Interpretasi
Normal Ini
1
2
3
4
5

12. Pemeriksaan Diagnostik

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

Analisa Data :
No Data Fokus Masalah Etiologi
1. DS :

DO:

2. DS :

DO :

3. DS :

DO :

Prioritas Masalah :
1. ..................................................................................................
..................................................................................................
2. ..................................................................................................
..................................................................................................
3. ..................................................................................................
..................................................................................................
 RENCANA KEPERAWATAN

Nama Klien :................................. Usia :...........bln/ thn

Jenis kelamin :.....................................Dx Medis :.......................
Tgl Masuk RS :...................................Tgl Pengkajian :.......................

DX Keperawatan Perencanaan
No
(Sesuai prioritas) Tujuan Intervensi Rasional

Tujuan :

Kriteria
Evaluasi :
(SMART)

PENGKAJIAN INI BOLEH DITAMBAHKAN SESUAI REFERENSI

YANG SAUDARA RUJUK. TIDAK HARUS BERUPA TABEL,
BOLEH DINARASIKAN SESUAI DENGAN REFERENSI YANG
SAUDARA RUJUK.