KEMENTERIAN KESEHATAN R.I.

POLITEKNIK KESEHATAN
PALANGKA RAYA

FORMAT
ASUHAN KEPERAWATAN ANAK

Pengkajian diambil : Tgl ............................................. Pukul : ............. WIB

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

I. IDENTITAS

A. KLIEN

Nama : ....................................................
Tempat & Tanggal Lahir : ....................................................
Jenis Kelamin : ....................................................
Suku / Bangsa : ....................................................
Agama : ....................................................
Pendidikan : ....................................................
Alamat : ....................................................
Diagnosa Medis : ....................................................
No. MR : ....................................................

B. PENANGGUNG JAWAB / ORANG TUA

Nama : ....................................................
Umur : ....................................................
Jenis Kelamin : ....................................................
Suku / Bangsa : ....................................................
Agama : ....................................................
Pekerjaan : ....................................................
Pendidikan : ....................................................
Hubungan Keluarga : ....................................................
Alamat : ....................................................

II. RIWAYAT PERAWATAN ( NURSING HISTORY )

A. Keluhan Utama

Modul PK-5 S.Tr.Kep Angkatan V // FORMAT ASKEP //Kepr Anak / 2021 / Fetty_TR 1
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B. Riwayat Penyakit

1. Riwayat Penyakit Sekarang ( PQRST, upaya yang dilakukan dan terapi )

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2. Riwayat Kehamilan dan Kelahiran

a. Prenatal : .............................................................
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b. Natal : .............................................................
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c. Postnatal : .............................................................
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3. Riwayat Masa Lampau

a. Penyakit waktu kecil : .............................................................
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b. Riwayat dirawat di rumah sakit : .............................................................
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c. Obat – obatan yang digunakan : .............................................................
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d. Tindakan medis : .............................................................
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e. Alergi : .............................................................
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f. Kecelakaan : .............................................................
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g. Imunisasi : .............................................................
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4. Riwayat Kesehatan Keluarga
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Modul PK-5 S.Tr.Kep Angkatan V // FORMAT ASKEP //Kepr Anak / 2021 / Fetty_TR 2
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Genogram Keluarga 3 ( tiga ) generasi

C. Riwayat Sosial
1. Pengasuh : .............................................................
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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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D. Kebutuhan Dasar
1. Makanan yang disukai / tidak disukai : .............................................................
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Selera : .............................................................
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Alat makan yang digunakan : .............................................................
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Pola makan / jam : .............................................................
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Modul PK-5 S.Tr.Kep Angkatan V // FORMAT ASKEP //Kepr Anak / 2021 / Fetty_TR 3
 2. Pola tidur : .............................................................
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Kebiasaan sebelum tidur : .............................................................

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Tidur siang : .............................................................

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3. Mandi : .............................................................
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4. Eliminasi : .............................................................
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5. Aktifitas bermain : .............................................................

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E. Keadaan Kesehatan Saat Ini

1. Diagnosa medis : .............................................................
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2. Tindakan operasi : .............................................................

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3. Status nutrisi : .............................................................

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4. Status cairan : .............................................................

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5. Obat - obatan : .............................................................

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6. Aktifitas : .............................................................
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Modul PK-5 S.Tr.Kep Angkatan V // FORMAT ASKEP //Kepr Anak / 2021 / Fetty_TR 4
 7. Tindakan perawatan : .............................................................
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8. Hasil laboratorium : .............................................................

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9. X - ray : .............................................................
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III. OBSERVASI DAN PEMERIKSAAN FISIK

A. Keadaan Umum
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B. Pemeriksaan Fisik

1. Tanda – tanda vital

S: 0
C R: x/menit N: x/menit TD : mmHg

2. Pengukuran antropometri
TB / PB / BB / LK
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3. Pemeriksaan Fisik
a. Kepala : .............................................................
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b. Mata : .............................................................
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c. Hidung : .............................................................
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d. Mulut : .............................................................
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Modul PK-5 S.Tr.Kep Angkatan V // FORMAT ASKEP //Kepr Anak / 2021 / Fetty_TR 5
 e. Telinga : .............................................................
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f. Leher : .............................................................
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g. Dada : .............................................................
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h. Jantung : .............................................................
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i. Paru - paru : .............................................................

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j. Perut : .............................................................
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k. Punggung : .............................................................
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l. Genetalia : .............................................................
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m. Ekstremitas : .............................................................
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n. Kulit : .............................................................
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IV. PEMERIKSAAN TINGKAT PERKEMBANGAN

A. Kemandirian dan bergaul : .............................................................

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B. Motorik halus : .............................................................

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C. Motorik kasar : .............................................................

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D. Kognitif dan bahasa : .............................................................

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V. INFORMASI LAIN
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VI. RINGKASAN KEPERAWATAN

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( ...............................................)

Inisial Klien :
No. MR :

Modul PK-5 S.Tr.Kep Angkatan V // FORMAT ASKEP //Kepr Anak / 2021 / Fetty_TR 7
 ANALISA DATA

Data
Kemungkinan Penyebab Masalah
( Subjektif dan objektif )

Inisial Klien :
No. MR :

Modul PK-5 S.Tr.Kep Angkatan V // FORMAT ASKEP //Kepr Anak / 2021 / Fetty_TR 8
 DAFTAR DIAGNOSA KEPERAWATAN SESUAI PRIORITAS

No
Diagnosa Keperawatan
.

Modul PK-5 S.Tr.Kep Angkatan V // FORMAT ASKEP //Kepr Anak / 2021 / Fetty_TR 9
 Inisial Klien :
No. MR :

RENCANA KEPERAWATAN

No Diagnosa
Hari / Tanggal Tujuan & Kriteria Hasil Rencana Tindakan Rasional
. Keperawatan

Modul PK-5 S.Tr.Kep Angkatan V // FORMAT ASKEP //Kepr Anak / 2021 / Fetty_TR 10
 Inisial Klien :
No. MR :

IMPLEMENTASI KEPERAWATAN

Waktu Diagnosa
Pelaksanaan Tindakan Evaluasi Tindakan / Respon Klien Paraf
( Hari, tanggal, jam ) Keperawatan

Modul PK-5 S.Tr.Kep Angkatan V // FORMAT ASKEP //Kepr Anak / 2021 / Fetty_TR 11
 Inisial Klien :
No. MR :

CATATAN PERKEMBANGAN

Waktu Diagnosa
Catatan Perkembangan Paraf
( Hari, tanggal, jam ) Keperawatan

Modul PK-5 S.Tr.Kep Angkatan V // FORMAT ASKEP //Kepr Anak / 2021 / Fetty_TR 12