Lampiran 1

FORMAT ASUHAN KEPERAWATAN ANAK

1. PENGKAJIAN

A. IDENTITAS KLIEN

Nama Klien : ..................................................

Tempat Tanggal Lahir : ...................................................

Agama : ...................................................

Alamat : ...................................................

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

Usia Ibu/Ayah : ...................................................

Pendidikan Ibu/Ayah : ...................................................

Pekerjaan Ibu/Ayah : ...................................................

Agama Ibu/Ayah : ...................................................

Suku Bangsa : ...................................................

Status Perkawinan : ...................................................

Alamat : ...................................................

B. RIWAYAT KESEHATAN

1. Keluhan utama

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

2 Riwayat kesehatan sekarang

......................................................................................................
 3 Riwayat kesehatan dahulu

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

4 Riwayat kesehatan

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

5 Genogram

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

6 Riwayat prenatal, intranatal, post natal

Anak ke Usia Jenis Penolong Ket:

sekarang persalinan hidup/mati

7 Riwayat tumbuh kembang

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

8 Riwayat sosial/pola asuh

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

9 Riwayat imunisasi

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

C. PENGKAJIAN POLA FUNGSIONAL GORDON

1. Nutrisi dan cairan

Asupan nutrisi : ...........................................

Nafsu makan : ...........................................

Asupan cairan (jumlah, jenis) : ............................................

Masalah khusus : ............................................

2. Pola eliminasi
 BAB: kebiasaan BAB : ...........................................

Masalah konstipasi/diare : ...........................................

BAK: kebiasaan BAK : ...........................................

Masalah khusus : ...........................................

D. PEMERIKSAAN FISIK

1 Keadaan Umum : ..............................................

Kesadaran : ..............................................

2 Tanda Vital

TD : ..................mmHg

Suhu : ..................oC

Nadi : .................. x/menit

Pernapasan : .................. x/menit

3 Tinggi Badan : ...................................................

4 Berat Badan : ...................................................

5 Lingkar Lengan Atas : ...................................................

6 Kepala

Leher : ...................................................

Kepala : ...................................................

Mata : ...................................................

Hidung : ...................................................

Mulut : ...................................................

Telinga : ...................................................
 Dada

7 Jantung : .....................................................

8 Paru-paru

Inspeksi : ....................................................

Palpasi : .....................................................

Perkusi : .....................................................

Auskultasi : .....................................................

9 Abdomen

Inspeksi : ....................................................

Auskultasi : ......................................................

Palpasi : ......................................................

Perkusi : ......................................................

10 Genetalia : .....................................................

11 Ekstremitas

Ekstremitas atas : ......................................................

Ekstremitas bawah : ......................................................

12 Kulit

Turgor : ......................................................

Warna : ......................................................

E. OBAT-OBATAN

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

F. HASIL PEMERIKSAAN PENUNJANG

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

G. ANALISA DATA

No Data Fokus Problem Etiologi

2. DIAGNOSA KEPERAWATAN

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

3. INTERVENSI

No Hari/tanggal Tujuan Intervensi Ttd

perawat

4. IMPLEMENTASI

No Hari/tanggal No DX Jam Tindakan Respon Ttd

Pasien perawat

5. EVALUASI

No Hari/tanggal Catatan Perkembangan Ttd Perawat