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JURUSAN PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS TRIBHUWANA TUNGGADEWI - MALANG

PENGKAJIAN KEPERAWATAN ANAK

Nama Mahasiswa : Tempat Praktik :

NIM : Tgl. Praktik :

A. PENGKAJIAN
1. Biodata Klien
a. Nama :
b. Umur :
c. Jenis kelamin :
d. Agama :
e. Suku / Bangsa :
f. Alamat :
g. No. Register :
h. Tanggal Masuk RS :
i. Tanggal Pengkajian :
j. Diagnosa Medis :
k. Nama Orang Tua :

2. Keluhan Utama

3. Riwayat Penyakit Sekarang

4. Riwayat Kehamilan dan Kelahiran

a. Riwayat ANC (Antenatal Care)

b. Riwayat Natal

c. Riwayat Post Natal

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5. Riwayat Imunisasi

6. Riwayat Penyakit Dahulu

7. Riwayat Kesehatan Keluarga

GENOGRAM

8. Riwayat Psikososial dan Status Spiritual

a. Aspek Psikologis

b. Aspek Sosial

c. Aspek Spiritual / Sistem Nilai Kepercayaan

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9. Pola Aktifitas-Latihan
Rumah Rumah Sakit
 Makan/minum .................................................... ....................................................
 Mandi .................................................... ....................................................
 Berpakaian/berdandan .................................................... ....................................................
 Toileting .................................................... ....................................................
 Mobilitas di tempat tidur ....................................................
 Berpindah .................................................... ....................................................
 Berjalan .................................................... ....................................................
Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = tidak mampu

10. Pola Nutrisi Metabolik

Rumah Rumah Sakit
 Jenis diit/makanan .............................................. .................................................
 Frekuensi/pola .............................................. .................................................
 Porsi yg dihabiskan .............................................. .................................................
 Komposisi menu .............................................. .................................................
 Pantangan .............................................. .................................................
 Nafsu makan .............................................. .................................................
 Jenis minuman .............................................. .................................................
 Frekuensi/pola minum .............................................. .................................................

11. Pola Eliminasi

Rumah Rumah Sakit
 BAB:
- Frekuensi/pola .................................................... .................................................
- Warna & Bau .................................................... .................................................
- Kesulitan .................................................... .................................................
- Upaya mengatasi .................................................... .................................................

 BAK:
- Frekuensi/pola .................................................... .................................................
- Warna & Bau .................................................... .................................................
- Kesulitan .................................................... .................................................
- Upaya mengatasi .................................................... .................................................

12. Pola Tidur-Istirahat

Rumah Rumah Sakit
 Tidur siang:Lamanya .............................................
 Tidur malam: Lamanya ............................................. ................................................
- Kesulitan .............................................. ...............................................

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13. Pola Kebersihan Diri

 Mandi:Frekuensi
- Penggunaan sabun
 Keramas: Frekuensi
- Penggunaan shampoo
 Gosok gigi: Frekuensi
- Penggunaan odol
 Kesulitan
Rumah
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Rumah Sakit
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Pola Perkembangan

14. Pemeriksaan Fisik

1. Keadaan umum :
a. Kesadaran :
b. Tanda-tanda vital : - Tekanan Darah : Suhu :
- Nadi : Pernafasan :
c. Tinggi Badan : Berat Badan :
LK : LD : LLA :
2. Kepala dan Leher
a. Kepala : Bentuk Massa
Distribusi rambut Warna kulit kepala
b. Mata : Bentuk Konjungtiva
Pupil : ( ) reaksi terhadap cahaya ( ) isokor ( )Miosis

Tanda-tanda radang :
Funsi penglihatan : ( ) Baik ( ) Kabur
c. Hidung : Bentuk ………….. Warna …………. Pembengkakan …………
Nyeri tekan …….. Perdarahan …………..
d. Mulut dan Tenggorokan :
Warna bibir ……… Mukosa …………… Ulkus …………………...
Lesi ……………… Massa …………….. Warna Lidah ……………
Perdarahan gusi ………………………….
e. Telinga : Bentuk …………… Warna ……………. Lesi ……………………
Massa ……………. Nyeri …………………………………………..
f. Leher : Kekakuan………………..Nyeri/Nyeri tekan…………………………
Benjolan/massa.............. Vena jugularis……………
3.Dada : Jantung : Inspeksi
Palpasi
Perkusi
Auskultasi …………………………………………………..
Paru : Inspeksi
Palpasi
Perkusi
Auskultasi …………………………………………………

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4. Payudara dan Ketiak :

Benjolan/massa ……………….. Nyeri/nyeri tekan ……………..
Bengkak …………………………
5.Abdomen :
Inspeksi ……………………………………………………………….
Auskultasi …………………………………………………………….
Palpasi ………………………………………………………………..
Perkusi ……………………………………………………………….
6. Genetalia :
Inspeksi ………………………………………………………………
Palpasi ………………………………………………………………..

7. Ekstremitas : Kekuatan otot ………………………………………………………

Kontraktur …………………………… Pergerakan ……………….
Deformitas ……………………………Pembengkakan …………….
Nyeri/nyeri tekan ……………….
Pus/luka …………………………

8. Kulit : Warna ……………………

Turgor ……………
CRT ……………….

15. Hasil Pemeriksaan Penunjang

Laboratorium

Radiologi

16. Terapi Pengobatan

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17. Kesimpulan

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Malang.
Pengkaji

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A. ANALISIS DATA

HARI/TGL : ...............................................................................................

NO DATA PENYEBAB MASALAH KEPERAWATAN

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B. DIAGNOSA KEPERAWATAN

NAMA & TANDA

NO TANGGAL DIAGNOSA KEPERAWATAN
TANGAN PERAWAT

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C. RENCANA TINDAKAN KEPERAWATAN

DIAGNOSA TUJUAN DAN KRITERIA NAMA DAN TTD

NO INTERVENSI RASIONAL
KEPERAWATAN HASIL PERAWAT

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D. IMPLEMENTASI TINDAKAN KEPERAWATAN

NAMA & TANDA

NO TANGGAL JAM TINDAKAN KEPERAWATAN TANGAN
PERAWAT

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E. EVALUASI
DIAGNOSA
NO
KEPERAWATAN
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TANGGAL
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Mengetahui,
Pembimbing Klinik
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Malang,..............................,...............
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Mahasiswa
NIM.
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