UNIVERSITAS NAHDLATUL ULAMA SURABAYA

FAKULTAS KEPERAWATAN DAN KEBIDANAN

PROGRAM STUDI PROFESI NERS
KAMPUS A JL. SMEA NO. 57 SURABAYA (031) 8291920, 8284508, FAX (031) 8298582
KAMPUS B RS. ISLAM JEMURSARI JL. JEMURSARI NO. 51-57 SURABAYA
Website : www.unusa.ac.id Email : info@unusa.ac.id

FORMAT PENGKAJIAN
ASUHAN KEPERAWATAN ANAK

Nama Mahasiswa : RS :
N I M : Ruangan :
Tanggal Pengkajian : Jam : WIB

I. IDENTITAS
II. PASIEN
a. Nama : ............................................................................
b. Nama Panggilan : ............................................................................
c. Umur : ............................................................................
d. Tanggal Lahir : ............................................................................
e. Jenis Kelamin : ............................................................................
f. Alamat : ............................................................................
g. Pendidikan : ............................................................................
h. Diagnosa : ............................................................................
i. Tgl Mrs : ............................................................................
j. No. Register : ............................................................................

III. ORANG TUA

a. Nama Ayah : ................................. Nama Ibu : ....................................
b. Umur : ................................. Umur : ....................................
c. Agama : ................................. Agama : ....................................
d. Suku : ................................. Suku : ....................................
e. Pendidikan : ................................. Pendidikan
: ....................................
f. Pekerjaan : ................................. Pekerjaan : ....................................
g. Penghasilan : ................................. Penghasilan : ....................................
h. Alamat : ................................. Alamat : ....................................
A. RIWAYAT KEPERAWATAN (NURSING HISTORY)
1. RIWAYAT PENYAKIT SEKARANG
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
2. KELUHAN UTAMA
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
3. RIWAYAT PENYAKIT SEBELUMNYA
a. Penyakit masa kecil
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
b. Riwayat MRS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
c. Riwayat pemakaian obat
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
d. Tindakan operasi
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
e. Alergi
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
f. Kecelakaan
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
g. Imunisasi
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. RIWAYAT KESEHATAN KELUARGA
 _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
5. RIWAYAT KESEHATAN LINGKUNGAN/SOSIAL :
a. Pengasuh anak
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
b. Hubungan dengan anggota keluarga
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
c. Hubungan dengan teman sebaya
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
d. Pembawaan umum
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
6. RIWAYAT KEHAMILAN DAN KELAHIRAN :
a. Perinatal
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
b. Natal
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
c. Post Natal

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

B. PEMENUHAN KEBUTUHAN DASAR

1. Pola makan
Sebelum Sakit Saat Sakit
Frekuensi
Menu
 Porsi
Yang disukai
Yang tidak disukai
Pantangan/Alergi
Gangguan

2. Pola minum
Sebelum Sakit Saat Sakit
Frekuensi
Jenis
Jumlah (cc/botol)
Yang disukai
Yang tidak disukai
Pantangan/Alergi
Gangguan

3. Istirahat tidur
Sebelum sakit Saat sakit
Tidur siang
Tidur malam
Gangguan

4. Eliminasi
Sebelum sakit Saat sakit
BAK
BAB
Gangguan

5. Personal hygiene
Sebelum sakit Saat sakit
Mandi
Sikat gigi
Ganti pakaian
Memotong kuku
Lain-lain

C. KESEHATAN SAAT INI

1. Diagnosa medis
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
 2. Tindakan operasi
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
3. Status nutrisi
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
4. Status hidrasi
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
5. Aktivitas saat MRS
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
D. PEMERIKSAAN FISIK
1. Keadaan umum
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
2. Tanda vital
Nadi : ____________ kali/menit
RR : ____________ kali/menit
Suhu : ____________ °C
3. Antopometri
BB : ____________ kg TB : _____________ cm
4. Pemeriksaan Kepala Leher
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
5. Pemeriksaan Integumen / Kulit
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
6. Pemeriksaan Payudara Dan Ketiak
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
7. Paru
 _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
8. Jantung
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
9. Pemeriksaan Abdomen
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
10. Pemeriksaan kelamin dan daerah sekitarnya
a. Genetalia
________________________________________________________________
________________________________________________________________
________________________________________________________________
b. Anus
________________________________________________________________
________________________________________________________________
________________________________________________________________
11. Pemeriksaan Muskuloskeletal
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
12. Pemeriksaan Neurologi
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

E. PEMERIKSAAN TUMBUHAN DAN KEMBAN

1. Adaptasi social
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
 2. Bahasa
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
3. Motorik kasar
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
4. Motorik halus
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
F. PEMERIKSAAN PENUNJANG
1. Laboratorium
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
2. Rontgen
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
3. USG
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
G. TERAPI MEDIS
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Surabaya.........................................

(...............................................)
NIM.
 ANALISA DATA

Nama Pasien : No. RM :

Umur : tahun/bulan Ruang :
NO DATA ( DS/DO) MASALAH ETIOLOGI

DAFTAR DIAGNOSA KEPERAWATAN

Nama Pasien : No. RM :
Umur : tahun/bulan Ruang :
NO DIAGNOSA KEPERAWATAN
 TINDAKAN KEPERAWATAN

Nama Pasien : No. RM :

Umur : tahun/bulan Ruang :
Tanggal/Jam No. Dx. Tindakan Keperawatan Paraf

CATATAN PERKEMBANGAN
Nama Pasien : No. RM :
Umur : tahun/bulan Ruang :
Tanggal/Jam No. Dx. Catatan Perkembangan Paraf

EVALUASI
Nama Pasien : No. RM :
Umur : tahun/bulan Ruang :
Tanggal/Jam No. Dx. Evaluasi Paraf