BAB III

PENGKAJIAN DAN FORMAT

Nama Mahasiswa : ....................................................................

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

FORMAT PENGKAJIAN ANAK

A. Identitas Pasien
Nama : ......................................................................................................................
Tempat/Tgl. Lahir : ......................................................................................................................
Nama Ayah/ Ibu : ......................................................................................................................
Pekerjaan Ayah : ......................................................................................................................
Pekerjaan Ibu : ......................................................................................................................
Suku : ......................................................................................................................
Agama : ......................................................................................................................
Pendidikan : ......................................................................................................................
Alamat : ......................................................................................................................
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B. Keluhan Utama
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C. Riwayat Kehamilan & Kelahiran

1. Prenatal : ......................................................................................................................
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2. Natal : ......................................................................................................................
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3. Postnatal : ......................................................................................................................
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D. Riwayat Masa Lalu
1. Penyakit waktu kecil : ....................................................................................................................
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2. Pernah dirawat dirumah sakit : .......................................................................................................
3. Obat-obatan yang digunakan : ........................................................................................................
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4. Tindakan operasi :
5. Alergi : ............................................................................................................................................
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6. Kecelakaan : ...................................................................................................................................
7. Riwayat imunisasi : ........................................................................................................................
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E. Riwayat Keluarga
1. Riwayat penyakit yang pernah dialami oleh anggota keluarga : ....................................................
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2. Genogram keluarga
Keterangan :
: Laki-Laki

: Perempuan

: Klien

: Meninggal

: Tinggal serumah

: Cerai
F. Riwayat Sosial
1. Yang mengasuh anak : ....................................................................................................................
2. Hubungan dengan anggota keluarga : ............................................................................................
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3. Hubungan dengan teman sebaya : ..................................................................................................
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4. Pembawaan secara umum : ............................................................................................................
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5. Lingkungan rumah : .......................................................................................................................
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G. Kebutuhan Dasar
1. Makanan :
a. Makanan yang disukai/tidak disukai : ......................................................................................
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b. Selera makan : ........................................................................................................................
c. Alat makan yang dipakai : ........................................................................................................
d. Pola makan : .............................................................................................................................
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2. Pola tidur :
a. Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda dibawa tidur) : ...................
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b. Tidur siang : .............................................................................................................................
3. Mandi : ............................................................................................................................................
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4. Aktivitas bermain :..........................................................................................................................
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5. Eliminasi : .......................................................................................................................................
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H. Keadaan Kesehatan Saat Ini
1. Diagnosa medis : ......................................................................................................................
2. Tindakan operasi : ......................................................................................................................
3. Status cairan : ......................................................................................................................
4. Obat-obatan : ......................................................................................................................
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5. Aktivitas : ......................................................................................................................
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6. Hasil Lab : ......................................................................................................................
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7. Foto rontgen : ......................................................................................................................
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8. Lain-laian : ......................................................................................................................
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I. Pemeriksaan Fisik
1. Keadaan umum : ......................................................................................................................
2. TB/BB : .......... cm, .........Kg
3. Lingkar kepala : ......................................................................................................................
4. Kepala : ......................................................................................................................
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5. Mata : ......................................................................................................................
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6. Leher : ......................................................................................................................
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7. Telinga : ......................................................................................................................
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 8. Hidung : ......................................................................................................................
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9. Mulut : ......................................................................................................................
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10. Dada : ......................................................................................................................
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11. Paru-paru : ......................................................................................................................
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12. Jantung : ......................................................................................................................
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13. Abdomen : ......................................................................................................................
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14. Punggung : ......................................................................................................................
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15. Genetalia : ......................................................................................................................
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16. Ektremitas
a. Ekstremitas atas : ............................................................................................................
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b. Ekstremitas bawah : ............................................................................................................
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17. Tanda-Tanda Vital :
a. Respirasi rate : ............ x/mnt (reguler/irreguler)
b. Heart rate : ............ x/mnt (reguler/irreguler)
c. Blood pressure : ......./........ mmHg
d. Temperature : ............... oC

J. Pemeriksaan Tingkat Perkembangan

1. Kemandirian bergaul :
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 2. Motorik halus :
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3. Motorik kasar :
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4. Kognitif :
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5. Bahasa :
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K. Informasi Tambahan Lainnya
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L. Ringkasan Riwayat Keperawatan
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M. Masalah Keperawatan
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DIAGNOSA KEPERAWATAN

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5. .................................................................................................................................................
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 ANALISA DATA

No DATA ETIOLOGI MASALAH

 NURSING CARE PLAN (NCP)
Nama Pasien : Ruang Rawat :
Umur : No. Register :
Jenis Kelamin : Diagnosa Medik :
Tujuan & Kriteria Hasil Intervensi
No Diagnosa Kep Rasionalisasi
(NOC) (NIC)
 CATATAN PERKEMBANGAN PASIEN

Nama Pasien : Ruang Rawat :

Umur : No. Register :
Jenis Kelamin : Diagnosa Medik :
No.
Hari/
Diagnosa Implementasi Evaluasi (SOAP) Paraf
Tanggal
Kep