Modul Early Clinical Exposure Keperawatan Anak 1

FORMAT PENGKAJIAN ANAK UNTUK PASIEN KELOLAAN

I. Identitas Pasien & Keluarga :

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

Usia :........................ Usia Ayah/Ibu : ......................
Jenis Kelamin :........................ Agama : ......................
Anak ke..... dari.... bersaudara........ Alamat : .....................
Tanggal Masuk :........................ Suku bangsa : ......................
Tgl Pengkajian :........................ Pendidikan : ......................
Diagnosa Medis : ......................... Pekerjaan : ......................

II. Keluhan Utama :

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

III. Keadaan Sakit Saat Ini (kembangkan PQRST)

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

IV. Riwayat Anak pada Masa

1. Prenatal...............................................................................................
............................................................................................................
............................................................................................................
2. Intranatal ............................................................................................
............................................................................................................
............................................................................................................
3. Postnatal .............................................................................................
............................................................................................................
V. Riwayat Kesehatan Masa lalu :
1. Riwayat penyakit sebelumnya : ................................................
2. Pernah dirawat di RS : ................................................
3. Obat-obatan yang digunakan : ................................................
4. Tindakan (operasi) : ................................................
5. Alergi : ................................................
6. Kecelakaan : ................................................
7. Imunisasi dasar : ................................................

VI. Riwayat Penyakit Keluarga (disertai Genogram), tuliskan sampai

dengan 2 generasi dalam keluarga
.................................................................................................................
.................................................................................................................
.................................................................................................................

VII. RIWAYAT SOSIAL :

1. Yang mengasuh .............................................................................
2. Hubungan dengan anggota keluarga .............................................
3. Hubungan dengan teman sebaya ...................................................
4. Pembawaan secara umum .............................................................
........................................................................................................
5. Lingkungan rumah .........................................................................
........................................................................................................

VIII. KEBUTUHAN DASAR

1. Nutrisi
........................................................................................................
........................................................................................................
........................................................................................................
2. Eliminasi
........................................................................................................
........................................................................................................
........................................................................................................
Modul Early Clinical Exposure Keperawatan Anak 23
 3. Istirahat tidur
........................................................................................................
........................................................................................................
........................................................................................................
4. Aktifitas
........................................................................................................
........................................................................................................
........................................................................................................

IX. Pemeriksaan Tingkat Pertumbuhan & Perkembangan

1. Pertumbuhan Fisik
........................................................................................................
........................................................................................................
........................................................................................................

2. Perkembangan Motorik Kasar

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

3. Perkembangan Motorik Halus

........................................................................................................
........................................................................................................
........................................................................................................
4. Perkembangan Bahasa
........................................................................................................
........................................................................................................
........................................................................................................
5. Perkembangan Sosial
........................................................................................................
 6.
Perkembangan Kognitif
........................................................................................................
........................................................................................................
........................................................................................................
Keterangan : untuk anak usia 0-6 tahun gunakan format DDST (DENVER
II) dan buatkan kesimpulan ditiap ranah perkembangan yang
telah dicapainya, untuk anak yang usia lebih dari 6 tahun
menggunakan pendekatan teori pertumbuhan dan
perkembangan sosial yang sesuai usianya. Untuk neonatus
perlu dikaji tentang reflek primitif.

X. Tinjauan Sistem :
1. Keadaan umum dan tanda-tanda vital :
KeadaaanUmum : ...........................................................................
........................................................................................................
a. TB dan BB : .................. dan........................................
b. Lingkar kepala :..................................................................
c. Lingkar lengan :..................................................................
d. Suhu :..................................................................
e. Nadi :..................................................................
f. Pernafasan :..................................................................
g. Tekanan darah :..................................................................
2. Pengkajian Kardiovaskuler :
a. Nadi, denyut apeks- frekuensi, irama dan kualitas : ................
.................................................................................................
Nadi perifer (ada/ tidak ada) : jika ada, frekuensi, irama,
kualitas dan perbedaan antar ekstremitas ................................
.................................................................................................
b. Pemeriksaan toraks dan hasil auskultasi :
Lingkar dada (toraks) : .............................................................
Adanya deformotas : .............................................................
Bunyi jantung : .............................................................
c. Tampilan Umum
Modul Early Clinical Exposure Keperawatan Anak 25
 Tingkat aktifitas : .....................................................................
Perilaku : apatis, gelisah, ketakutan :.......................................
Jari tabuh (dubbling) pada tangan dan kaki : ...........................
.................................................................................................
d. Kulit
Warna : .........................................................................
Elastisitas : .........................................................................
Suhu tubuh : .........................................................................
e. Edema
Periorbital : .........................................................................
Ekstremitas : ..........................................................................

3. Pengkajian Respitarori
a. Bernafas :
Frekuensi pernafasan, kedalam dan kesemitrisan : ..................
.................................................................................................
.................................................................................................
Pola Nafas: apnea, takipnea :...........................................
Retraksi : ..........................................
Pernafasan cuping hidung :...........................................
Posisi yang nyaman : ..........................................
b. Hasil Auskultasi toraks
Bunyi nafas :...........................................
Fase Ekspirasi dan inspirasi memanjang : ...............................
.................................................................................................
.................................................................................................
c. Hasil pemeriksaan toraks :
Lingkar dada : ......................................................................
Bentuk dada : ......................................................................

4. Pengkajian Neurologi
a. Tingkat kesadaran (hasil GCS) :.................................................
b. Pemeriksaan kepala :
 Bentuk kepala : ...................................................................
Fontanel : ...................................................................
Lingkar kepala (dibawah 2 tahun): ..........................................
c. Reaksi Pupil
Ukuran :...................................................
Reaksi terhadap cahaya :...................................................
d. Aktifitas Kejang
Jenisnya : ...................................................................
Lamanya : ...................................................................
e. Fungsi sensoris
Reaksi terhadap nyeri : ............................................................
.................................................................................................
f. Refleks
Refleks tendon dan superficial :...............................................
.................................................................................................
Refleks patologis : ...................................................................

g. Kemampuan intelektual (tergantung tingkat perkembangan)

Perkembangan menulis & menggambar :
................................
.................................................................................................
Kemampuan membaca :...........................................................
.................................................................................................
5. Pengkajian Gastrointestinal
a. Hidrasi
Turgor Kulit : ...........................................................
Membran mukosa : ...........................................................
Asupan & haluaran : ..........................................................
.................................................................................................
b. Abdomen
Nyeri : ...........................................................
Kekakuan : ...........................................................
Bising usus : ...........................................................
 Muntah (jumlah, frekuensi dan karakteristik) :
.................................................................................................
.................................................................................................
Feses (frekuensi dan karakteristik) :
.................................................................................................
.................................................................................................
Kram : ...................................................................................
.................................................................................................

6. Pengkajian Renal/ Ginjal

a. Fungsi Ginjal :
Nyeri tekan pinggang atau suprapubik: ...................................
.................................................................................................
Disuria : ................................................................................
.................................................................................................
Pola berkemih (lancar/ menetes) .............................................
Adanya acites : ...........................................................
Adanya edema pada (skrotum, periorbital, tungkai bawah):
.................................................................................................
.................................................................................................
b. Karakteristik urine dan urinasi :
Urine tampak bening atau keruh : .................................
Warna : .................................
Bau (amoniak atau aseton) : .................................
Berat Jenis : .................................
Menangis saat berkemih :
c. Genetalia :
Iritasi : ...................................................................................
Seklret : ...................................................................................
7. Pengkajian Muskuloskeletal
a. Fungsi Motorik Kasar :
Ukuran Otot (adanya atropi/ hipertropi otot) :
.................................................................................................
 Tonus Otot (spastis, rentang gerak terbatas) :
.................................................................................................
.................................................................................................
Kekuatan : ........................................................
Gerakan Abnormal : .........................................................
b. Fungsi Motorik Halus :
Manipulasi mainan : .........................................................
Menggambar : .........................................................
c. Kontrol Postur
Mempertahankan posisi tegak : ...............................................
Bergoyang-goyang : ........................................................
d. Persendian
Rentang gerak : ..............................................
Kontraktur : ..............................................
Adanya edema dan nyeri : ..............................................
Tonjolan abnormal : ...............................................
e. Tulang Belakang
Lengkung tulang belakang (Scoliosis, kiposis): ......................
.................................................................................................

8. Pengkajian Hematologi
a. Kulit :
Warna : ..............................................
Adanya ptechea, memar : ..............................................
Perdarahan dari membran mukosa atau dari luka suntikan/
fungsi vena
.................................................................................................
b. Abdomen :
Pembesaran hati : ..............................................
Pembesaran Limpa : ..............................................
9. Pengkajian Endokrin
a. Status Hidrasi
Poliuria : ..............................................
Polifagia : ..............................................
Polidipsi : ..............................................

Kulit kering : ..............................................

b. Tampilan Umum
Alam perasaan : ..............................................
Iritabilitas : ..............................................
Sakit Kepala : ..............................................
Gemeteran : ..............................................

10. Obat-obatan Saat ini :

Kontra- Efek
No Nama Obat Dosis Indikasi
indikasi Samping
1
2
3
4
5
6
7
8

11. Pemeriksaan Laboratorium :

Nilai Nilai saat
No Jenis pemeriksaan Interpretasi
Normal Ini
1
2
3
4
5
12. Pemeriksaan Diagnostik
........................................................................................................
........................................................................................................
........................................................................................................

Analisa Data :
No Data Fokus Masalah Etiologi
1. DS :

DO:

2. DS :

DO :

3. DS :

DO :

Prioritas Masalah :
1. ...................................................................................................
...................................................................................................
2. ...................................................................................................
...................................................................................................
3. ...................................................................................................
...................................................................................................
 RENCANA KEPERAWATAN

Nama Klien :................................. Usia..................................bln/ thn

Jenis kelamin :............................... ..... Dx Medis :........................
Tgl Masuk RS :.............................. ..... Tgl Pengkajian :........................

DX Keperawatan Perencanaan
No Tujuan Intervensi Rasional
(Sesuai prioritas)

Tujuan :

Kriteria
Evaluasi :
(SMART)
 CATATAN TINDAKAN KEPERAWATAN

Nama Klien :................................. Usia..................................bln/ thn

Jenis kelamin :............................... ..... Dx Medis :........................
Tgl Masuk RS :.............................. ..... Tgl Pengkajian :........................

No Implementasi
Tgl/ Jam Respon Pasien Paraf
DX Keperawatan
 CATATAN PERKEMBANGAN KEPERAWATAN

Nama Klien :................................. Usia..................................bln/ thn

Jenis kelamin :............................... ..... Dx Medis :........................
Tgl Masuk RS :.............................. ..... Tgl Pengkajian :........................

Tgl/ Evaluasi
No Dx Paraf
Jam (SOAP)