YAYASAN KARYA HUSADA KEDIRI AS N

YAYEDIRA
K I
STIKES KARYA HUSADA KEDIRI
Ijin Mendiknas RI No. 164/D/O/2005 Rekomendasi Depkes RI No. HK.03.2.4.1.03862
PROGRAM STUDI PROFESI NERS

KA

A
RY

D
Jl. Soekarno Hatta, Kotak Pos 153, Telp/Fax. (0354) 395203 Pare Kediri A HUSA
Website: www.stikes-khkediri.ac.id

FORMAT PENGKAJIAN
KEPERAWATAN ANAK
I. DATA UMUM

Nama : ……………………………………………………………
Ruang : ……………………………………………………………
No. Register : ……………………………………………………………
Umur : ……………………………………………………………
Jenis Kelamin : ……………………………………………………………
Agama : ……………………………………………………………
Suku Bangsa : ……………………………………………………………
Bahasa : ……………………………………………………………
Alamat : ……………………………………………………………
Pekerjaan : ……………………………………………………………
Penanggung jawab : …………………………………………………………
Pendidikan Terakhir : ……………………………………………………………
Golongan Darah : ............................................................................................
Tanggal MRS : ……………………………………………………………
Tanggal Pengkajian : ……………………………………………………………
Diagnosa Medis : ……………………………………………………………

II. DATA DASAR

Keluhan Utama :
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Alasan Masuk Rumah Sakit :

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Riwayat Penyakit Sekarang :

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Upaya yang telah dilakukan:

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Terapi yang telah diberikan:

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 Riwayat Kesehatan Dahulu : .................................................................................
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Riwayat Kesehatan Keluarga : .................................................................................

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Genogram:

III. RIWAYAT ANTENATAL & POST NATAL

1. Riwayat selama kehamilan
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2. Obat-obatan yang digunakan

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3. Tindakan operasi
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4. Riwayat alergi
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5. Kecelakaan
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6. Imunisasi
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IV. PENGKAJIAN PERKEMBANGAN (DDST ATAU KPSP)

1. Motorik Kasar
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 2. Motorik Halus
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3. Personal Sosial
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4. Bahasa
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V. RIWAYAT SOSIAL
1. Pengasuh
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2. Hubungan dengan anggota keluarga juga saudara

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3. Pembawaan secara umum

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4. Lingkungan rumah
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VI. POLA FUNGSI KESEHATAN

1. Persepsi terhadap Kesehatan – Manajemen Kesehatan

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2. Pola Aktivitas dan Latihan

 Kemampuan Perawatan Diri

Skor 0 : mandiri, 1 : dibantu sebagian, 2 : perlu bantuan orang lain, 3 : perlu
bantuan orang lain dan alat, 4 : tergantung pada orang lain / tidak mampu.

Aktivitas 0 1 2 3 4
Mandi
Berpakaian
Eleminasi
Mobilisasi di tempat tidur
Pindah
Ambulasi
Naik tangga
Makan dan minum
Gosok gigi

Keterangan : ..............................................................................................................
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3. Pola Istirahat dan Tidur :

KETERANGAN SEBELUM SAKIT SAAT SAKIT
Jumlah Jam Tidur Siang

Jumlah Jam Tidur Malam

Pengantar Tidur

Gangguan Tidur

Perasaan Waktu Bangun

4. Pola Nutrisi – Metabolik

1) Berat badan sebelum sakit dan saat sakit
Tanggal Pemeriksaan BB sebelum sakit BB saat sakit

2) Tinggi badan atau panjang badan

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3) Kebiasaan pemberian makanan

KETERANGAN SEBELUM SAKIT SAAT SAKIT
Frekuensi

Jenis

Porsi
 Total Konsumsi

Keluhan

4) Diit khusus
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5) Tanda kecukupan nutrisi (NCHS atau menyesuaikan RS setempat)

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5. Pola Eliminasi
Eliminasi Uri
KETERANGAN SEBELUM SAKIT SAAT SAKIT
Frekuensi

Pancaran

Jumlah

Bau

Warna

Perasaan setelah BAK

Total Produksi Urin

Eliminasi Alvi
KETERANGAN SEBELUM SAKIT SAAT SAKIT
Frekuensi

Konsistensi

Bau

Warna

6. Pola Kognitif dan Persepsi Sensori

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7. Pola Konsep Diri

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 8. Pola Mekanisme Koping
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9. Pola Fungsi Seksual – Reproduksi

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10. Pola Hubungan - Peran

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11. Pola Nilai dan Kepercayaan
KETERANGAN SEBELUM SAKIT SAAT SAKIT
Nilai Khusus

Praktik Ibadah

Pengetahuan tentang
Praktik Ibadah selama sakit

12. Pola aktivitas bermain

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VII. PEMERIKSAAN FISIK (DATA OBYEKTIF)

1. Status Kesehatan Umum

Keadaan/ penampilan umum:
Kesadaran : GCS:
BB sebelum sakit : TB:
BB saat ini :
BB ideal :
Perkembangan BB :
Status Gizi :
Status Hidrasi :
Tanda – tanda vital :
TD :
N :
Suhu :
RR :

2. Pemeriksaan Fisik (Head To Toe/B1-B6)

A. Head To Toe
1) Kepala dan Leher
 2) Dada/Thorak

3) Abdomen/Perut

4) Ekstremitas dan kulit

5) Genetalia

B. ( B1 – B6 )
1) B1 (Breathing)

2) B2 (Blood)

3) B3 (Brain)

4) B4 (Bladder)

5) B5 (Bowel)

6) B6 (Bone)
C. Pemeriksaan Diagnostik
1) Laboratorium

2) Radiologi

3) Pemeriksaaan penunjang lainnya

D. Terapi
1. Oral

2. Parenteral

3. Lain - lain