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YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN
Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536) 3227707
E-Mail : stikesekaharap110@yahoo.com

FORMAT PENGKAJIAN ANAK

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

Nim : ……………………………………………………….
Tempat Praktek : ……………………………………………………….
Tanggal Pengkajian & Jam : ……………………………………………………….

2.1 Pengkajian
2.1.1 Anamnesa
2.1.1.1 Identitas Pasien
Nama Klien : ........................................................
TTL : ........................................................
Jenis Kelamin : ........................................................
Agama : ........................................................
Suku/Bangsa : ........................................................
Pendidikan : ........................................................
Alamat : ........................................................
Diagnosa Medis : ........................................................
2.1.1.2 Identitas Penanggung Jawab
Nama : ........................................................
TTL : ........................................................
Jenis Kelamin : ........................................................
Agama : ........................................................
Suku/Bangsa : ........................................................
Pendidikan : ........................................................
Alamat : ........................................................
Hubungan Keluarga : ........................................................

2.1.1.3 Keluhan Utama

..............................................................................................................................
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.......................................................................................................................
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2.1.1.4 Riwayat Kesehatan

1) Riwayat Kesehatan sekarang
..............................................................................................................................
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2) Riwayat Kesehatan lalu
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3) Riwayat Kesehatan Keluarga
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4) Susunan Genogram
KET :
= Laki-Laki
= Perempuan
= Meninggal
= Pasien
= Tinggal Serumah

Gambar. 2.1Genogram keluarga

2.1.2 Pemeriksaan Fisik

2.1.2.1 Keadaan Umum
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Tanda-tanda Vital
Nadi : .............. x/menit
Suhu : ..............0C
Respirasi: ............ x/menit
2.1.2.2 Kepala dan Wajah
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2.1.2.3 Leher dan Tenggorokan
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2.1.2.4 Mulut dan Faring
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........................................................................................................................................
..
2.1.2.5 Dada
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2.1.2.6 Abdomen
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2.1.2.7 Eliminasi
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2.1.2.8.Ekstremitas
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2.1.2.7 Genetalia
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2.1.3 Riwayat Pertumbuhan dan Perkembangan
2.1.3.1 Gizi Selera makan
Pola Makan Sehari- Sesudah Sakit Sebelum Sakit
hari
Frekuensi/hari ............ x sehari ............. x sehari
Porsi ...... piring makan ....... piring makan
Nafsu makan ................ ...................
Jenis Makanan ................................. ..............................
Jenis Minuman ............................ ............................
Jumlah minuman ............ cc/24 jam ............. cc/24 jam
Kebiasaan makan ............................ ..................................
Keluhan/masalah ........................... ..................................

2.1.3.2 Kemandirian dalam bergaul

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2.1.3.3 Motorik halus

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2.1.3.4 Motorik Kasar
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2.1.3.5 Kognitif dan bahasa
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2.1.3.6 Psikososial
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2.1.4 Pola Aktivitas Sehari-hari
No Pola Kebiasaan Keterangan

Nutrisi
a. Frekuensi a. .........................................................
b. Nafsu Makan/selera b. .........................................................
c. Jenis Makanan c. .........................................................
Eliminasi
a. BAB a. ............ x/hari
b. BAK b. .................. sehari.
Istirahat dan tidur
a. Siang/jam a. .............. jam
b. Malam/jam b. .............. jam
Personal Hyigene
a. Mandi a. ....... x/hari
b. Oral Hygene b. ....... x/hari

2.1.5 Data Penunjang

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.............................................................................................................................
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Mahasiswa,

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ANALISA DATA
DATA SUBYEKTIF DAN DATA KEMUNGKINAN MASALAH
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OBYEKTIF PENYEBAB
DS :

DO :

PRIORITAS MASALAH
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 RENCANA KEPERAWATAN
Nama Pasien:
Ruang Rawat:
Diagnosa Tujuan (Kriteria Hasil) Intervensi Rasional
Keperawatan
Setelah dilakukan tindakan
keperawatan
selama ...........jam
pertemuan ...........................
..................
KRITERIA HASIL:
(1) ...................................
(2) ....................................
(3) ....................................
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IMPLEMENTASI DAN EVALUASI KEPERAWATAN

No. Tanda tangan dan

Hari/Tanggal
Dx Implementasi Evaluasi (SOAP) Nama Perawat
Jam

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