I.

IDENTITAS DATA
Nama Anak : ....................................................... BB/TB : .............................
TTL/ Usia : .....................................................................................................
Jenis Kelamin : .....................................................................................................
Pendidikan Anak : .....................................................................................................
Anak ke : .....................................................................................................
Nama Ibu : .....................................................................................................
Pekerjaan : .....................................................................................................
Pendidikan : .....................................................................................................
Alamat : .....................................................................................................
Diagnosis Medis : .....................................................................................................

II. KELUHAN UTAMA

(Alasan Masuk RS) : .....................................................................................................
.....................................................................................................
.....................................................................................................
III. RIWAYAT KEHAMILAN DAN KELAHIRAN
1. Prenatal : .....................................................................................................
2. Intranatal : .....................................................................................................
3. Postnatal : .....................................................................................................
IV. RIWAYAT KESEHATAN SAAT INI
...................................................................................................................................

V. RIWAYAT KESEHATAN DAHULU

1. Penyakit yang diderita sebelumnya : ....................................................................
2. Pernah dirawat di RS : ...........................................................................................
3. Obat-obatan yang pernah digunakan : ...................................................................
4. Alergi : ...................................................................................................................
5. Kecelakaan : ..........................................................................................................
6. Riwayat imunisasi : ...............................................................................................

VI. RIWAYAT KESEHATAN KELUARGA

Disertai genogram 3 (tiga) generasi
...................................................................................................................................

VII. RIWAYAT TUMBUH KEMBANG

1. Kemandirian dan bergaul : ....................................................................................
2. Motorik Kasar : .....................................................................................................
3. Motorik Halus : .....................................................................................................
4. Kognitif dan Bahasa : ............................................................................................
5. Psikososial : .........................................................................................................
6. Lain-lain : .........................................................................................................

VIII. RIWAYAT SOSIAL

1. Yang mengasuh klien : ..........................................................................................
2. Hubungan dengan anggota keluarga : ...................................................................
3. Hubungan dengan teman sebaya : ........................................................................
4. Pembawaan secara umum : ...................................................................................
5. Lingkungan rumah : ..............................................................................................
IX. PEMERIKSAAN FISIK
1. Keadaan umum : ...................................................................................................
2. TB/ BB (cm) : ........................................................................................................
3. Kepala
a. Lingkar kepala : .................................................................................................
b. Rambut :
Kebersihan : ......................................................................................................
Warna : ..............................................................................................................
Tekstur : .............................................................................................................
Distribusi rambut : ............................................................................................
Kuat/mudah tercabut : ......................................................................................
4. Mata :
a. Simetris : .........................................................................................................
b. Sclera : .........................................................................................................
c. Konjungtiva : .....................................................................................................
d. Palpebra : .........................................................................................................
e. Pupil : Ukuran…….Bentuk…….
f. Reaksi Cahaya : .................................................................................................
5. Telinga :
a. Simetris : .........................................................................................................
b. Serumen : .........................................................................................................
c. Pendengaran : ....................................................................................................
6. Hidung :
a. Septum simetris : ...............................................................................................
b. Sekret : .........................................................................................................
c. Polip : .........................................................................................................
7. Mulut : Kebersihan : .........................................................................................
Warna Bibir : .........................................................................................
Kelembapan : .........................................................................................
a. Lidah : .....................................................................................................
b. Gigi : .....................................................................................................
8. Leher
a. Kelenjer Getah Bening : ....................................................................................
b. Kelenjer Tiroid : ................................................................................................
c. JVP : ..................................................................................................................
9. Dada
a. Inspeksi : .....................................................................................................
b. Palpasi : .....................................................................................................
10. Jantung
a. Inspeksi : .....................................................................................................
b. Palpasi : .....................................................................................................
c. Auskultasi : .....................................................................................................
11. Paru-paru
a. Inspeksi : .....................................................................................................
b. Palpasi : .....................................................................................................
c. Perkusi : .....................................................................................................
d. Auskultasi : .....................................................................................................
12. Abdomen
a. Inspeksi : .....................................................................................................
b. Palpasi : .....................................................................................................
c. Perkusi : .....................................................................................................
d. Auskultasi : .....................................................................................................
13. Punggung : Bentuk ........................................................................................
14. Ekstremitas :
Kekuatan dan tonus otot : ...................................................................................
Refleks-refleks : ...................................................................................................
a. Atas : .....................................................................................................
b. Bawah : .....................................................................................................
15. Genitalia : .....................................................................................................
16. Kuli :
Warna .................. Tugor ...............Integritas .............. Elastisitas .....................
17. Pemeriksaan neurologis :
Berkaitan dengan kasus seperti meningitis, kejang dll.
 X. PEMERIKSAAN PERTUMBUHAN
- STATUS GIZI

XI. PEMERIKSAAN PSIKOSOSIAL

XII. PEMERIKSAAN CAIRAN Intake dan output cairan

XIII. PEMERIKSAAN SPIRITUAL

XIV. PEMERIKSAAN PENUNJANG

1. Laboratorium:
2. Rontgen :
3. Lain-lain :

XV. KEBUTUHAN DASAR SEHARI-HARI

No Jenis Kebutuhan Di Rumah/ Di Rumah Sakit

sebelum sakit
1 Makan
2 Minum
3 Tidur
4 Mandi
5 Eliminasi
6 Bermain

XVI. RINGKASAN RIWAYAT KEPERAWATAN

(Berisikan tentang alasan masuk RS, identitas klien, BB dan TB, TTV,
semua data/ pengkajian yang abnormal/data fokus dan nantinya
akan dimasukkan sebagai DO dan DS)