Nama Mahasiswa :

NBP :
Tempat Praktek :
Tanggal Pengkajian :
Tanggal klien masuk :
No. RM : .....................................................................................................
I. IDENTITAS DATA
Nama Anak :
BB/TB :
TTL/ Usia :
Jenis Kelamin :
Pendidikan Anak :
Anak ke :
Nama Ibu :
Pekerjaan :
Pendidikan :
Alamat :
Diagnosis Medis :
II. KELUHAN UTAMA (Alasan Masuk
RS) : ..................................................................................................... ......
............................................................................................... .....................
................................................................................
III. III. RIWAYAT KEHAMILAN DAN KELAHIRAN
1. Prenatal :
2. Intranatal :
3. Postnatal :
IV. RIWAYAT KESEHATAN SAAT
INI ..............................................................................................................................
.....
V. RIWAYAT KESEHATAN DAHULU
1. Penyakit yang diderita sebelumnya : ....................................................................
2. Pernah dirawat di RS : ...........................................................................................
3. Obat-obatan yang pernah digunakan : ...................................................................
4. Alergi : ...................................................................................................................
5. Kecelakaan : ..........................................................................................................
6. Riwayat imunisasi : ...............................................................................................
VI. RIWAYAT KESEHATAN
KELUARGA .................................................................................................................
..................
VII. RIWAYAT TUMBUH KEMBANG
1. Kemandirian dan bergaul : ....................................................................................
2. Motorik Kasar : .....................................................................................................
3. Motorik Halus : .....................................................................................................
4. Kognitif dan Bahasa : ............................................................................................
5. Psikososial : .........................................................................................................
6. Lain-lain : .........................................................................................................
VIII. RIWAYAT SOSIAL
1. Yang mengasuh klien : ..........................................................................................
2. Hubungan dengan anggota keluarga : ...................................................................
3. Hubungan dengan teman sebaya : ........................................................................
4. Pembawaan secara umum : ...................................................................................
5. Lingkungan rumah : ..............................................................................................
IX. PEMERIKSAAN FISIK
1. Keadaan umum : ...................................................................................................
2. TB/ BB (cm) : ........................................................................................................
3. Kepala
a. Lingkar kepala : .................................................................................................
b. Rambut : Kebersihan :
Warna : ..............................................................................................................
Tekstur : .............................................................................................................
Distribusi rambut : ............................................................................................
Kuat/mudah tercabut : ......................................................................................
4. Mata :
a. Simetris : .........................................................................................................
b. Sclera : .........................................................................................................
c. Konjungtiva : .....................................................................................................
d. Palpebra : .........................................................................................................
e. Pupil : Ukuran…….Bentuk…….
f. Reaksi Cahaya : .................................................................................................
5. Telinga :
a. Simetris : .........................................................................................................
b. Serumen : .........................................................................................................
c. Pendengaran : ....................................................................................................
6. Hidung :
a. Septum simetris : ...............................................................................................
b. Sekret : .........................................................................................................
c. Polip : .........................................................................................................
7. Mulut :
a. Lidah : .....................................................................................................
b. Gigi : .....................................................................................................
8. Leher
a. Kelenjer Getah Bening : ....................................................................................
b. Kelenjer Tiroid : ................................................................................................
c. JVP : ..................................................................................................................
9. Dada
a. Inspeksi : .....................................................................................................
b. Palpasi : .....................................................................................................
10. Jantung
a. Inspeksi : .....................................................................................................
b. Palpasi : .....................................................................................................
c. Auskultasi : .....................................................................................................
11. Paru-paru
a. Inspeksi : .....................................................................................................
b. Palpasi : .....................................................................................................
c. Perkusi : .....................................................................................................
d. Auskultasi : .....................................................................................................
12. Abdomen
a. Inspeksi : .....................................................................................................
b. Palpasi : .....................................................................................................
c. Perkusi : .....................................................................................................
d. Auskultasi : .....................................................................................................
13. Punggung : Bentuk ........................................................................................
14. Ekstremitas : Kekuatan dan tonus otot :
a. Atas : .....................................................................................................
b. Bawah : .....................................................................................................
15. Genitalia : .....................................................................................................
16. Kulit : Warna .................. Tugor ...............Integritas ..............
Elastisitas .....................
17. Pemeriksaan neurologis : Berkaitan dengan kasus seperti meningitis, kejang
dll.
X. PEMERIKSAAN PERTUMBUHAN - STATUS GIZI
XI. PEMERIKSAAN PSIKOSOSIAL
XII. PEMERIKSAAN CAIRAN Intake dan output cairan
XIII. PEMERIKSAAN SPIRITUAL
XIV. PEMERIKSAAN PENUNJANG
1. Laboratorium : ...............................................................................................
2. Rontgen : .....................................................................................................
3. Lain-lain : .....................................................................................................
XV. KEBUTUHAN DASAR SEHARI-HARI No Jenis Kebutuhan Di Rumah/
sebelum sakit Di Rumah Sakit 1 Makan 2 Minum 3 Tidur 4 Mandi 5 Eliminasi 6
Bermain
XVI. RINGKASAN RIWAYAT KEPERAWATAN (Berisikan tentang alasan
masuk RS, identitas klien, BB dan TB, TTV, semua data/ pengkajian yang
abnormal/data fokus dan nantinya akan dimasukkan sebagai DO dan DS)
XVII. ANALISIS DATA (minimal 3 masalah keperawatan) No. Data
3DWR¿VLRORJL Masalah
XVIII. DIAGNOSIS KEPERAWATAN BERDASARKAN PRIORITAS (NANDA)
XIX. ASUHAN KEPERAWATAN No Hari/ tanggal Diagnosis Keperawatan
Tujuan dan Kriteria Hasil (NOC)
Intervensi (NIC)
XX. CATATAN PERKEMBANGAN No Dx. Hari/ Tanggal Implementasi Evaluasi
Paraf Perawat S:
O:
A:
P: