FORMAT PENGKAJIAN

Fakultas Ilmu-Ilmu Kesehatan

ANAK SEHAT
Program Studi S1 Keperawatan (0-72 bulan)
Universitas Nusa Nipa
2021
Non Scholae Sed Vitae Discimus Belajar Bukan Hanya Untuk Sekolah Melainkan Untuk Hidup

Tanggal pengkajian : ……………………………………………………

Jam : …………………………………………………….
Sumber Data : …………………………………………………….

A. PENGKAJIAN
1. IDENTITAS
a. ANAK
Nama :
Tempat tgl. lahir :
Jenis kelamin :
Anak ke :
Pendidikan :
Alamat :
Jumlah saudara :
b. ORANG TUA
Nama Ayah/Ibu :
Pekerjaan Ayah Atau Ibu :
Pendidikan Ayah/Ibu :
Suku/Bangsa :
Agama :
Penanggung Jawab :

2. RIWAYAT PENYAKIT SEKARANG

a. Keluhan utama :
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b. Riwayat keluhan utama:

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3. RIWAYAT TUMBUH KEMBANG ANAK

a. Deteksi Dini Pertumbuhan
Pemeriksaan Hasil Normal Interpretasi hasil
Antripometri
Berat Badan

Tinggi Badan

Lingkar Kepala

b. Deteksi Dini Perkembangan

Pemeriksaan Umur Hasil Interpretasi hasil
anak
KPSP

Tes Daya
Dengar

Tes Daya Lihat

Catatan : formulir hasil pemeriksaan KPSP, tes daya dengar dan tes daya lihat dilampirkan di ASKEP

Deteksi perkembangan dengan menggunakan formulir DDST

Pengkajian Penilaian (jelaskan) Interpretasi hasil (jelaskan)
a. Perkembangan Personal
Sosial

b. Adaptif – motoric halus

c. Perkembangan bahasa
 d. Motoric kasar

Catatan:
1. Formulir hasil pemeriksaan DDST dilampirkan
2. Penilaian : lebih/advance(perkembangan anak lebih), ok atau normal, caution/peringatan,
delayed/keterlambatan
3. Interpretasi hasil : normal, suspect, untestable(tidak dapat di uji)

4. RIWAYAT IMUNISASI
No Jenis Imunisasi Usia Pemberian Reaksi Setelah Pemberian
1 Hepatitis B(< 24 Jam)
2 BCG
3 Polio Tetes 1
4 DPT-HB-Hib 1
5 Polio Tetes 2
6 DPT-HB-Hib 2
7 Polio Tetes 3
8 DPT-HB-Hib 3
9 Polio Tetes 4
10 Polio Suntik (IPV)
11 Campak-Rubela (MR)
12 DPT-HB-Hib lanjutan
13 Campak –Rubela (MR)
Lanjutan

B. KLASIFIKASI DATA
 Hari / Tanggal : ……………………………....
Nama Klien/ Usia : ………………………….......

Data Subyektif :
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Data Obyektif : (Termasuk Hasil Pemeriksaan tumbuh kembang anak)

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C. ANALISA DATA

Hari / Tanggal : ……………………………........................................................................

 Nama Klien/ Usia : …………………………....... /..................................................................

No Data Etiologi Problem

D. DIAGNOSA KEPERAWATAN
Hari / Tanggal : ……………………………........................................................................
 Nama Klien/ Usia : …………………………....... /......................................................

PRIORITAS MASALAH KEPERAWATAN :

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E. PATOFLOW KASUS
 F. RENCANA KEPERAWATAN

NAMA KLIEN : ....................................................

NAMA MAHASISWA : .......................................................................................
NIM : ....................................................
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