AKADEMI KEPERAWATAN KERTA CENDEKIA

Jl. Lingkar Timur, Rangkah Kidul Sidoarjo 61232

Telp/Fax : (031) 8961496 - 8961497

Pengkajian Keperawatan Anak

Identitas
Nama :
Usia :
Nama Ayah : Usia :
Nama Ibu : Usia :
Alamat :
Agama :
Pekerjaan Ayah :
Pekerjaan ibu :

Riwayat keperawatan
Keluhan Utama/Alasan MRS
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Riwayat penyakit saat ini
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Riwayat Keperawatan Sebelumnya
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Penyakit yang pernah diderita
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Kecelakaan yang pernah dialami
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Operasi : .................................................................. Alergi : .......................................................

Riwayat persalinan
1) Pre natal care
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2) Natal
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3) Post Natal
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Riwayat Imunisasi
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 Riwayat kesehatan keluarga
1) Penyakit yang pernah diderita oleh anggota keluarga
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2) Lingkungan rumah dan komunitas
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3) Perilaku yang mempengaruhi kesehatan
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Riwayat tumbuh kembang

Berat badan sebelum sakit : .........kg ( 2 minggu sebelum sakit)
Berat badan saat sakit : ................kg
Tinggi badan : .............................cm
Berat badan ideal menurut DDST:
(umur (thn) x 2) + 8 = .................
Erupsi gigi pertama
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Tahap perkembangan psikososial (sesuai usia)
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Tahap perkembangan psikoseksual (sesuai usia)
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Perkembangan motorik halus (sesuai usia)
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Perkembangan motorik kasar (sesuai usia)
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Perkembangan sosialisasi (sesuai usia)
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Perkembangan bahasa (sesuai usia)
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Kemampuan menolong diri sendiri (sesuai usia)
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Genogram (3 generasi)
Riwayat nutrisi
Pemberian ASI
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Pemberian susu formula
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Pola perubahan nutrisi tiap tahap usia sampai nutrisi saat ini
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3.1.5.1 Pola nutrisi sehari-hari
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3.1.5.2 Cairan
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Riwayat psikososial
Tempat tinggal anak
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Hubungan antar anggota keluarga
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Pengasuh anak
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Persepsi keluarga terhadap penyakit anak
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Observasi dan pengkajian fisik

Keadaan umum klien
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Tanda-tanda vital
o
Suhu : C Respirasi : x/menit
Nadi : x/menit TD : mmHg

Antropometri
Tinggi badan : cm LLA : cm
Berat badan : kg, Lingkar Dada : cm
Lingkar Kepala : cm Lingkar Perut : cm
Sistem pernafasan
Inspeksi
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Palpasi
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Perkusi
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Auskultasi
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Masalah Keperawatan
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Sistem kardiovaskuler
Inspeksi
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Palpasi
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Perkusi
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Auskultasi
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Masalah Keperawatan
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Sistem persyarafan
Kesadaran : GCS :
Kejang : Kaku kuduk :
Nyeri Kepala :
Kelainan Nervus Cranialis :
Kebiasaan Istirahat/ Tidur
Dirumah (Sebelum Sakit)
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Dirumah (Saat Sakit)
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Di Rumah Sakit
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Masalah Keperawatan
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Sistem Genitourinaria
Bentuk Alat Kelamin :  Normal  Tidak Normal
Uretra :  Normal  Tidak Normal
Kebersihan : …………………….
Frekuensi :……………… x/hari  Teratur  Tidak Teratur
Jumlah : ………………. ml/24 jam
Bau : ……………………………. Warna : ……………………………
Tempat yang digunakan : …………………………
Masalah Keperawatan
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Sistem pencernaan
Mulut : ................................................................................
Mukosa : ..............................................................................
Bibir:  Normal  Labiokisis  Palatokisis
Gigi:  Bersih  Kotor  Ada caries  Tidak ada caries
Kebiasaan gosok gigi:..............................................................................
Tenggorokan:  Kesulitan menelan
Tidak ada kesulitan
Kemerahan
Pembesaran tonsil
Abdomen:  Tegang  Asites  Kembung  Nyeri tekan
Peristaltik :......................x/mnt
Kebiasaan BAB:..............................................., Konsistensi:......................
Warna:............................, Bau:...............................
Tempat yang biasa digunakan:................................................
Masalah eliminasi alvi:.................................................................................
Pemakaian obat pencahar:..........................................................................
Lavement:
Lain-lain
Masalah Keperawatan
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Sistem muskuloskeletal dan integumen

Kemampuan pergerakan sendi dan tungkai  Bebas  Terbatas
Kekuatan otot/ Tonus otot

Fraktur :  Ada, lokasi..................  Tidak

Dislokasi :  Ada  Tidak
Kulit : .............................................................................................................
Akral : ..........................................................................................................
Turgor : .........................................................................................................
Kelembapan : ................................................................................................
Oedema : ..............................................
Kebersihan kulit : ............................................................................
Lain-lain : .........................................................................
Masalah Keperawatan
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Sistem penginderaan
Mata :
Pupil : ...............................................................................................................
Reflek cahaya : ................................................................................................
Konjungtiva : ...................................................................................................
Sklera : ............................................................................................................
Palpebra : ........................................................................................................
Strabismus : ......................................................................................................
Ketajaman penglihatan:...................................................................................
Alat bantu : .......................................................................................................
Lain-lain : .........................................................................................................
Hidung :  Normal  Epistaksis
Mukosa hidung : .........................................................................................
Sekret : ..........................................................................................................
Ketajaman penciuman : Normal  Tidak
Kelainan lain : .....................................................................
Telinga : Bentuk : ................................................
Keluhan : ................................................................................
Ketajaman pendengaran : .......................................................................
Alat bantu : ...........................................................................................
Perasa :  Manis  Pahit  Asam  Asin
Peraba:.......................................................................
Masalah Keperawatan
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Sistem Endokrin
Kelenjar Thyroid  Pembesaran  Tidak terjadi pembesaran
Kelenjar Parotis  Pembesaran  Tidak terjadi pembesaran
 Hiperglikemia  Hipoglikemia
Masalah Keperawatan
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Pemeriksaan diagnostik

Terapi

Sidoarjo,

(Nama Mahasiswa)
 ANALISA DATA
Tanggal :
Nama pasien :
Umur :
No. RM :

No. Data Penyebab Masalah

 Diagnosa Keperawatan

Daftar Masalah Keperawatan

1.
2.
3.
4.

Daftar Diagnosa Keperawatan Berdasarkan Prioritas

1.
2.
3.
4.
 RENCANA TINDAKAN KEPERAWATAN

Tanggal :
Nama pasien :
Dx Medis :
No. RM :

No. Tujuan/kriteria hasil Intervensi Rasional

 IMPLEMENTASI KEPERAWATAN

Nama pasien : No. RM : Umur :

No. Dx Tanggal Jam Implementasi Nama/ tanda tangan

 CATATAN PERKEMBANGAN

Nama pasien : No. RM : Umur :

Tanggal Diagnosa Keperawatan Catatan perkembangan Paraf

 EVALUASI KEPERAWATAN

Nama pasien : No. RM : Umur :

Tanggal Diagnosa Keperawatan Evaluasi Paraf