FORMAT PENGKAJIAN KEPERAWATAN ANAK

Nama mahasiswa :...................................................

Tempat Praktik :...................................................

Tanggal Praktik :...................................................

A. ANAMNESA
Tanggal masuk RS :........................ Jam : ...........................

Tanggal pengkajian :........................ Jam : ...........................

1. Identitas
a. Identitas Klien
1) Nama :
2) No.RM :
3) Jenis kelamin :
4) Tempat/tanggal lahir :
5) Alamat :
6) Suku bangsa :
7) Agama :
8) Pendidikan :
9) Anak :
10) Diagnosa :

b. Identitas Penanggung Jawab Klien

1) Nama ayah :
2) Nama ibu :
3) Pekerjaan ayah :
4) Pekerjaan ibu :
5) Pendidikan ayah :
6) Pendidikan ibu :
7) Alamat :

2. Riwayat Kesehatan
a. Keluhan utama
Jelaskan :................................................................................................................................
...........................................................................................................

b. Alasan masuk RS
Jelaskan :................................................................................................................................
...........................................................................................................
c. Penanganan selama dirumah
Jelaskan :................................................................................................................................
...........................................................................................................

d. Riwayat kesehatan yang lampau

Jelaskan :................................................................................................................................
...........................................................................................................

e. Faktor pencetus kekambuhan

Jelaskan :................................................................................................................................
...........................................................................................................

f. Riwayat kehamilan dan kelahiran

1) Prenatal : ....................................................................................
2) Natal : ....................................................................................
3) Post Natal : BB..........., PB..........., LK........... , APGAR .................
g. Neonatal (Imunisasi):
1) Dasar :.......................... Jenis :....................................
2) Ulang :.......................... Jenis :....................................
h. Pertumbuhan dan Perkembangan
1) Motorik
a) Mengguling, umur : ....................................
b) Duduk, umur : ....................................
c) Merangkak, umur : ....................................
d) Berdiri, umur : ....................................
e) Berjalan, umur : ....................................
2) Sosial Kognitif
1) Tersenyum, umur : ....................................
2) Mengucapkan kata pertama, umur : ....................................
3) Bermain, umur : ....................................
4) Sekolah, umur : ....................................
i. Frekuensi Perawatan Sebelumnya:
1) Tanggal dirawat : ....................................
2) Alasan dirawat : ....................................
3). Lama dirawat : ....................................
4) Diagnosa
j. Riwayat kecelakaan/cedera : ....................................
k. Riwayat alergi : ....................................
l. Riwayat Kesehatan Keluarga : ....................................

3. Genogram
 Jelaskan :.................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
.................................................................................................................

4. Riwayat Sosial
a. Pengasuh :
b. Hubungan dengan anggota keluarga :
c. Teman sebaya :
d. Pembawaan secara umum :
e. Lingkungan rumah :

5. Nutrisi
Jenis makanan Sebelum di RS Saat di RS
Makanan 24 jam terakhir
Makanan yang disukai
Makanan yang tidak
disukai
Alat makan yang dipakai
Jam makan
Alergi makanan

6. Cairan
Sebelum di RS Saat di RS
Intake
Output
IWL
Kebutuhan
cairan

7. Pola Eliminasi
Sebelum di RS Saat di RS
Pola BAB
 Pola BAK

Perubahan
pola eliminasi
Keringat

8. Pola Aktivitas dan Latihan

Sebelum di RS Saat di RS
Kegiatan sehari-hari

Tingkat perawatan diri

Penggunaan waktu luang

Sebelum sakit Saat sakit

ADL
Dibantu Dibantu Dibantu Dibantu
Mandiri Mandiri
sebagian penuh sebagian penuh
Makan

Berpakaian
Toileting
Mandi
Mobilitas

9. Pola Tidur dan Istirahat

Sebelum di RS Saat di RS
Jam tidur
Pengantar tidur
Teman tidur
Gangguan tidur

10. Pola Persepsi dan Kognitif

a. Fungsi penglihatan, pendengaran, penciuman, peraba, nyeri
Jelaskan :.................................................................................................................
............................................................................................

b. Respon terhadap suara berisik, sentuhan, perbincangan dan musik

 Jelaskan :.................................................................................................................
............................................................................................

c. Pengalaman pendidikan
Jelaskan :.................................................................................................................
............................................................................................

d. Pola berbicara
Jelaskan :.................................................................................................................
............................................................................................

e. Kemampuan untuk bekerja sama dan berkomunikasi

Jelaskan :.................................................................................................................
............................................................................................

f. Kebiasaan yang terlihat oleh orang tua

Jelaskan :.................................................................................................................
............................................................................................

11. Pola Persepsi dan Konsep diri

a. Penampilan
Jelaskan :.................................................................................................................
............................................................................................

b. Kebiasaan
Jelaskan :.................................................................................................................
............................................................................................

c. Interest
Jelaskan :.................................................................................................................
............................................................................................

d. Yang menyebabkan ketakutan dan marah, bagaimana mengatasinya:

Jelaskan :.................................................................................................................
............................................................................................

e. Humor
Jelaskan :.................................................................................................................
 ............................................................................................

12. Pola Peran dan Hubungan

a. Yang biasa mengasuh
Jelaskan :.................................................................................................................
............................................................................................

b. Sibling
Jelaskan :.................................................................................................................
............................................................................................

c. Interaksi dengan teman sebaya

Jelaskan :.................................................................................................................
............................................................................................

d. Respon terhadap perpisahan

Jelaskan :.................................................................................................................
............................................................................................

e. Kemandirian
Jelaskan :.................................................................................................................
............................................................................................

f. Sekolah
Jelaskan :.................................................................................................................
............................................................................................

13. Pola Reproduksi Sosial

a. Pengetahuan tentang jenis kelaminnya
Jelaskan :.................................................................................................................
............................................................................................

b. Teman dekat
Jelaskan :.................................................................................................................
............................................................................................
 c. Menarche (perempuan)
Jelaskan :.................................................................................................................
............................................................................................

d. Sirkumsisi (laki-laki)
Jelaskan :.................................................................................................................
............................................................................................

14. Pola koping

Jelaskan :
…………………………………………………………………………………….
…………………………………………………………………………………
…

B. PEMERIKSAAN FISIK
1. Keadaan umum
Jelaskan :.........................................................................................................................
....................................................................................................

2. Kesadaran
Jelaskan :.........................................................................................................................
....................................................................................................

3. Tanda-tanda vital
Nadi :.............x/mnt RR :............. x/mnt T : .............oC TD: ............ mmHg

4. Antropometri
Tinggi badan : ....................cm
Berat badan : ....................kg

5. Status gizi :
Jelaskan :.........................................................................................................................
....................................................................................................

6. Head to toe
a. Kepala
Bentuk :.......................................................................................................
 Wajah :.......................................................................................................

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

Telinga :......................................................................................................

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

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

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

b. Dada :
Bentuk :................................................................................................

Paru- paru

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

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

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

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

Jantung

Inspeksi :................................................................................................
 Auskultasi :................................................................................................

c. Abdomen
Auskultasi :................................................................................................

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

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

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

d. Genetalia
Jelaskan :.................................................................................................................
.............................................................................................

e. Ekstremitas
Jelaskan :.............................................................................
.................................................................

f. Integumen