PROGRAM STUDI DIPLOMA III KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN SATRIA BHAKTI NGANJUK

Jl. Panglima Sudirman VI Nganjuk (0358) 326110

FORMAT PENGKAJIAN PEDIATRIK

Data diambil tanggal : ...................................... Jam : ....................................

Ruang rawat/kelas : ................................................
No. Rekam medik : ................................................

I. Identitas Anak II. Identitas Orangtua

Nama : Nama Ayah :
Tanggal lahir : Nama Ibu :
Jenis kelamin : Pekerjaan Ayah/Ibu :
Tanggal MRS : Pendidikan Ayah/Ibu :
Alamat : Agama :
Diagnosa Medis Suku Bangsa :
Sumber Informasi Alamat :

II. Riwayat Keperawatan

1. Riwayat Keperawatan Sekarang
a. Keluhan Utama : ........................................................................................
b. Riwayat Penyakit saat ini : ........................................................................................
...........................................................................................................................................
...............................................................................................................................

2. Riwayat Keperawatan Sebelumnya

a. Riwayat Kesehatan masa lalu : ............................................................................
...........................................................................................................................................
..........................................................................................................................
b. Riwayat Persalinan
1). Prenatal : ....................................................................................................
....................................................................................................
....................................................................................................
2). Natal : ....................................................................................................
...................................................................................................
3). Post Natal :
Neonatus : …………………………………………………
………………………………………………….
Infant ( 1 bulan – 1 tahun ) : …………………………………………………
Toddler ( 1 – 3 tahun ) : …………………………………………………
Prasekolah ( 4 – 6 tahun ) : …………………………………………………
Sekolah ( 7 – 12 tahun ) : …………………………………………………
Imunisasi
- Hepatitis B ............................................................................................................
- BCG ......................................................................................................................
- DPT .......................................................................................................................
- Polio ......................................................................................................................
 - Campak .................................................................................................................

3. Riwayat Kesehatan keluarga

a. Penyakit yang pernah/masih diderita oleh anggota keluarga :....................................
.....................................................................................................................................
b. Genogram ( 3 generasi )

4. Riwayat Pertumbuhan dan Perkembangan

a. Pertumbuhan
- Berat badan ..........................................................................................................
- Panjang badan ......................................................................................................
- Lingkar kepala ......................................................................................................
- Lingkar lengan atas ...............................................................................................
- Lingkar dada .........................................................................................................

b. Perkembangan
- Motorik kasar ........................................................................................................
- Motorik halus ........................................................................................................
- Sosial ....................................................................................................................
- Bahasa ...................................................................................................................

c. Tahap perkembangan
- Psikososial ............................................................................................................
- Psikoseksual ..........................................................................................................
- Kognitif..................................................................................................................

5. Spiritual
a. Anak ...........................................................................................................................
b. Orangtua ....................................................................................................................

6. Pengetahuan keluarga
.................................................................................................................................................
...........................................................................................................................

7. Kebutuhan dasar neonatus / anak

.................................................................................................................................................
.....................................................................................................................................
III. Pola Aktivitas sehari – hari
1. Pola istirahat dan tidur
a. Istirahat ..........................................................................................................
b. Tidur
 Frekwensi ...............................................................................................
 jumlah jam tidur ........................................................................................
 masalah tidur .............................................................................................
2. Pola aktivitas .......................................................................................................
3. Pola nutrisi
a. Makan (frekwensi, porsi, komposisi, diet) .....................................................
b. Minum (jumlah, jenis,jadwal)........................................................................
4. Pola eliminasi
a. BAB ............................................................................................................
b. BAK ...............................................................................................................
5. Pola Kebersihan Diri (personal hygiene) ............................................................

IV. Observasi dan pemeriksaan fisik

1. Keadaan umum dan tanda – tanda vital
a. Kesadaran ......................................................................................................
b. Tekanan darah ...............................................................................................
c. Nadi ...............................................................................................................
d. Pernafasan .....................................................................................................
e. Suhu ...............................................................................................................

2. Kepala .................................................................................................................
3. Mata .....................................................................................................................
4. Telinga .................................................................................................................
5. Hidung .................................................................................................................
6. Mulut ...................................................................................................................
7. Leher ....................................................................................................................
8. Dada .....................................................................................................................
9. Abdomen .............................................................................................................
10. Lengan .................................................................................................................
11. Punggung .............................................................................................................
12. Genetalia ..............................................................................................................
13. Pinggul, bokong, dan anus ..................................................................................
14. Neurologis
a. Reflek fisiologis ............................................................................................
b. Reflek patologis .............................................................................................
c. Saraf otak (N. Neurologia) ............................................................................

V. Pemeriksaan penunjang / tes diagnostik

a. Laboratorium .......................................................................................................
b. Foto roxen ............................................................................................................
c. USG .....................................................................................................................
d. ECG .....................................................................................................................
VI. Terapi Medis
..........................................................................................................................................
..............................................................................................................................

Nganjuk, ...............................2018
Mahasiswa

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