LAMPIRAN

PENGKAJIAN KEPERAWATAN ANAK

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Lampiran 11

FORMAT PENGKAJIAN ANAK

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

Tempat Praktek : …………….......................................................................................................…………………
Tanggal Praktek : …………….......................................................................................................…………………

Pengkajian Dilakukan Tanggal................jam................WIB

I. IDENTITAS
Inisial Nama : Alamat : banyuasin
…….....................................................……
Tempat/tgl.lahir : …………………... Agama : islam …….....................................................
……
Usia : …………………... Suku Bangsa : …….....................................................……
Nama Ayah/Ibu : rahadi / ridanti Pendidikan ayah :sma …….....................................................……
Pekerjaan Ayah : buruh Pendidikan ibu :sma …….....................................................
……
Pekerjaan Ibu : irt

II. RIWAYAT KEPERAWATAN

a. Keluhan Utama (saat masuk RS) demam (sejak tanggal 7 nov) sakit, pernah kenal covid,
( msuk ruangan tgl 9)
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b. Keluhan utama (saat pengkajian) gagal ginjal, msih demam, gelisah
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c. Riwayat Perjalanan Penyakit : pernah menjalanin pernyakit seperti ini, pernah dirawat dirs
( dirujuk ), 10 kali operasi dlm sebulan ( tgl 12 op)
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d. Riwayat Kehamilan dan Kelahiran Anak (anaak ke2)
- anak ke 1 dri 4 bersaudara (cwok semua)
- anak ke 1 dari 4 bersaudara ( cwek semua)

Prenatal : ………………………………………..............................................................................................

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 Internatal : …………………………………………...........................................................................................

Postnatal : …………………………………….................................................................................................
e. Riwayat Masa Lampau
1.Penyakit waktu kecil : …………………………...................................................................................
2.Pernah dirawat di RS : …………………………………….....................................................................
3.Obat-obatan yang digunakan: …………………………………….....................................................................
4.Tindakan (operasi) : …………………………………….....................................................................
5.Alergi …………………………………….....................................................................
6.Kecelakaan : …………………………………….....................................................................
7.Imunisasi : tidak imunisasi campak
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f. Riwayat Keluarga
Genogram
g. Riwayat Sosial
Yang mengasuh : …………………………….................................………...........................
Hubungan dengan anggota keluarga : …………………………….................................………...........................
Hubungan dengan teman sebaya : …………………………….................................………...........................
Pembawaan secara umum : …………………………….................................………...........................
Lingkungan rumah : …………………………….................................………...........................

IV. KEADAAN KESEHATAN SAAT INI

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V. PENGKAJIAN FISIK (12 DOMAIN NANDA)

1. PROMOSI KESEHATAN (KESADARAN & MANAJEMEN KESEHATAN)
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Masalah keperawatan:
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2. NUTRISI (MAKAN, PENCERNAAN, ABSORPSI, METABOLISME & HIDRASI)
a. Mulut
Trismus ( ), Halitosis ( )
Bibir: lembab( ), pucat( ), sianosis( ), labio/palatoskizis( ), stomatitis( )
Gusi: ( ), plak putih( ), lesi( )
Gigi: Normal( ), Ompong( ), Caries( ), Jumlah gigi:...................
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 Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
b. Leher
Kaku Kuduk ( ) Simetris( ), Benjolan ( ) Tonsil ( )
Kelenjar Tiroid : normal ( ), pembesaran ( )
Tenggorok : kesulitan menelan ( ), dll..................................................................................................
Kebutuhan Nutrisi dan Cairan
BB sebelum sakit: 9 kg BB sakit: kg
Makanan yang disukai:..........................
Selera makan:...........................
Alat makan yang digunakan:........................
Pola makan( x/ hari):......................
Porsi makan yang dihabiskan:............................
Pola Minum .............................gelas/hari) jenis air minum:.....................................................
c. Abdomen
Inspeksi : Bentuk: simetris( ), tidak simetris( ), kembung( ), asites( ),
Palpasi : massa ( ), nyeri ( )
Kuadran I :
Kuadran II :
Kuadran III :
Kuadran IV :
Auskultasi : bising usus........................x/mnt
Perkusi : Timpani ( ), redup ( )
Data Tambahan :
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Masalah keperawatan:
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3. ELIMINASI & PERTUKARAN (FUNGSI URINARIUS, GASTROINTESTINAL & PERNAPASAN)

Pola Eliminasi
BAK:
Warna:
Konsistensi:
Frekuensi: x/ hari
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 Urine Output : cc
Penggunaan Kateter:................................................................................................................................
Vesika Urinaria: Membesar .....................Nyeri tekan............................
Gangguan; Anuaria ( ), Oliguria ( ), Retensi Uria ( ), nokturia ( ), Inkontinensia Urin ( ),
Poliuria ( ), Dysuria ( )
Jelaskan:...............................................................................................................

BAB : warna........................................Frekuensi................................x/hari
Konsisitensi:.................................... lendir ( ), darah ( ), ampas ( )
Konstipasi ( )

Jalan nafas: Sputum ( ), warna sputum ( ) konsisitensi:........................................

Batuk ( ) frekuensi:..............................

Dada
Bentuk: Simetris ( ), Barrel chest/dada tong( ), pigeon chest/dada burung ( ) benjolan ( ),
dll………………..

Paru-paru:
Inspeksi: RR………x/ min,
Palpasi: Normal ( ), ekspansi pernafasan( ), taktil fremitus( )
Perkusi: Normal/ Sonor( ), redup/pekak( ), hiper sonor( )
Auskultasi: irama( ), teratur( ),
Suara nafas: vesicular( ), bronkial( ), Amforik ( ), Cog Wheel Breath Sound ( )
metamorphosing breath sound ( )
Suara Tambahan: Ronki ( ), pleural friction( )
Data Tambahan :
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Masalah keperawatan:
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4. AKTIVITAS / ISTIRAHAT (ISTIRAHAT, AKTIVITAS, KESEIMBANGAN ENERGI, RESPON
KARDIOVASKULAR / PULMONAL & PERAWATAN DIRI)
Jantung
Inspeksi: ictus cordis/denyut apeks( ), normal( ) melebar( )
Palpasi: kardiomegali( )
Perkusi: redup( ), pekak( )
Auskultasi: HR...............x/mnt. Aritmia( ),Disritmia( ) , Murmur ( )
Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa saat tidur,dll):
Kebiasaan Tidur siang:......................................jam/hari
Skala Aktivitas:
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi/ROM
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total

Personal hygine :
Mandi:...................x/hari
Sikat gigi :........................................x/hari
Ganti Pakaian :..................................x/hari
Memotong kuku:...............................x/hari
Data Tambahan :
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Masalah keperawatan:
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5. PERSEPSI / KOGNISI (PERHATIAN, ORIENTASI, SENSASI PERSEPSI, KOGNISI & KOMUNIKASI)

a. Kesan Umum

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 Tampak Sakit: ringan ( ), sedang ( ), berat ( ), pucat ( ), sesak ( ), kejang ( )
b. Kepala
Bentuk:........................ Hematoma( ), Luka( )
Fontanel: cekung ( ), Datar ( ), Keras ( ), Lunak ( )
Rambut: warna...............mudah dicabut ( ), ketombe( ), kutu( )
c. Mata
Mata: jernih( ), mengalir, kemerahan( ), sekret( )
Visus: 6/6( ), 6/300( ), 6/ tak terhingga( ),
Pupil: Isokor( ), anisokor( ), miosis( ), midriasis( ),
reaksi terhadap cahaya: kanan Positif( ), negatif( ), kiri negatif( ) positif( ),
alat bantu: kacamata( ), Softlens( )
Conjungtiva: merah jambu( ), anemis( )
Sklera: Putih( ), Ikterik( )
d. Telinga
Simetri( ), sekret( ), radang( ), Pendengaran: ( ), kurang( ), tuli( )
e. Hidung : Simetris( ), pilek( ), epistaksis( )
f. Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
Data Tambahan :
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Masalah keperawatan:
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6. PERSEPSI DIRI (KONSEP DIRI, HARGA DIRI,& CITRA TUBUH)

Perasaaan klien terhadap penyakit yang didieritanya.............................................................................
Persepsi klien terhadap dirinya.........................................................................................................................
Konsep diri....................................................................................................................................................................
Tingkat kecemasan....................................................................................................................................................
CitraDiri/Bodyimage:..............................................................................................................................................
Data Tambahan :
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Masalah keperawatan:
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7. HUBUNGAN PERAN (PERAN PEMBERI ASUHAN, HUBUNGAN KELUARGA & PERFORMA PERAN)
Masalah sosial yang penting:
Hubungan orang tua dan bayi:
Orang terdekat yang dapat dihubungi:
Orang tua berespon terhadap penyakit: ya ( ) tidak ( )
Respon:
Orang tua berespon terhadap hospitalisasi: ya ( ) tidak ( )
Data Tambahan
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Masalah keperawatan:
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8. SEKSUALITAS (IDENTITAS, FUNGSI SEKSUALITAS & REPRODUKSI)

Genitalia dan Anus
Laki-laki
Penis: normal/ada ( ), Abnormal…………………,
Scrotum dan testis: normal( ), hernia( ), hidrokel( )
Anus ; normal/ada ( ), atresia ani( )
Perempuan
Vagina: sekret( ), warna( )
Anus: normal/ada ( ), atresia ani( )
Data Tambahan
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Masalah keperawatan:
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9. KOPING / TOLERANSI STRESS (RESPONS PASCATRAUMA, RESPON KOPING & STRES
NEUROBIHAVIOUR)
GCS :.......
E:........................................................................................
V: .......................................................................................
M:.......................................................................................
Reflek Patologis :
Babinsky .............................................................................................................
Kernig ...........................................................................................................
Brudzinsky..................................................................................................
Reflek Fisiologis:
Biceps.................................................................................................................
Triceps...............................................................................................................
Patella........................................................................
Data Tambahan
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Masalah keperawatan:
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10. PRINSIP HIDUP (NILAI, KEYAKINAN & KESELARASAN / KEYAKINAN)

Budaya :
Spritual / Religius :
Harapan :
Psikososial :
Data Tambahan
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Masalah keperawatan:
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11. KEAMANAN / PERLINDUNGAN (INFEKSI, CEDERA FISIK, KEKERASAN, BAHAYA

LINGKUNGAN, PROSES PERTAHANAN, & TERMOREGULASI)
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 Tingkat Kesadaran : Composmentis ( ), Apatis ( ), Somnolen ( ),
Sopor (),Soporocoma ( ) Coma ( )
TTV : Suhu.............O C, Nadi........x/min, TD...............mmHg, RR..........x/min
Warna kulit :
Sianosis ( ), I kterus ( ), eritematosus rash ( ), discoid lupus ( ),
oedema ( ),
Bula ( ), Ganggren ( ), nekrotik jaringan ( ), Hiperpigmentasi ( )
Echimosis ( ), Petekie ( )
Turgor Kulit: elastis ( ), tidak elastis ( )
Data Tambahan
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Masalah keperawatan:
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12. KENYAMANAN (FISIK, LINGKUNGAN & SOSIAL)

Nyeri : Ya ( ) Tidak ( )
Jika ya, Pengkajian nyeri :
P (Provokatif/paliatif)
Q( Quality)
R(Regio)
S(Scale)
T(Time)
Data Tambahan
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Masalah keperawatan:
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13. PERTUMBUHAN / PERKEMBANGAN

PEMERIKSAAN TINGKAT PERKEMBANGAN (DDST/KPSP)
Kemandirian dan bergaul : …………….................................………………………..................
………………………………….................................….......,..........
Motorik Halus : …………………………................................…….........................
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 Kognitif dan bahasa : ………………………………................................…......................
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Motorik kasar : ……………………………................................………...................
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Data Tambahan
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Masalah keperawatan:
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TERAPI

Terapi Cara Pemberian Dosis Golongan / Jenis Indikasi

PEMERIKSAAN PENUNJANG

Tanggal Pemeriksaan

ANALISA DATA

DATA KLIEN Etiologi Masalah Keperawatan

DS : PATOFLOW

DO :

PRIORITAS MASALAH KEPERAWATAN

1……………………………………………………….
2……………………………………………………….
3……………………………………………………….

DIAGNOSA KEPERAWATAN
1………………berhubungan dengan……,...
2 Risiko………faktor risiko…………………...
3……………………………………………………….

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 RENCANA KEPERAWATAN

Nama Pasien : Diagnosa Medis :

Jenis kelamin : Hari/Tanggal :
No.Kamar/Bed : Shift :

No Dx. Keperawatan Tujuan (NOC) Intervensi (NIC)

Label NIC : .....................
Setealah dilakukan tindakan 1. Monitor / kaji
.............berhubungan keperawatan...x24 jam, pasien diharapkan 2.Tindakan mandiri
menunjukkan perbaikan “..............(Label perawat
dengan............ditandai
NOC) dengan kriteria hasil : 3.Penkes pasien /
dengan :
1 keluarga
DS : Indikator Awal Tujuan
4.Kolaborasi dengan
DO : 1.
tim medis lain
2.
(Dokter/ahli gizi/
3.
fisioterapi)

...........faktor risiko........
2

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 IMPLEMENTASI KEPERAWATAN

Nama Pasien : Diagnosa Medis :

Jenis kelamin : Hari/Tanggal :
No.Kamar/Bed : Shift :
Nama & TT
Dx. Tanggal & Implementasi keperawatan Respons Perawat
Keperawatan Waktu

EVALUASI KEPERAWATAN

Nama Pasien : Diagnosa Medis :

Jenis kelamin : Hari/Tanggal :
No.Kamar/Bed: Shift :

Dx. Tanggal & Evaluasi

Keperawatan Jam Paraf
S :

O:

A:

Indikator Awal Sekarang Tujuan

1.
2.

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 3.

P :

Lampiran 12

FORMAT PENGKAJIAN NEONATUS dan NICU

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

Tempat Praktek : ………………………........................................................................................................………
Tanggal Praktek : ………………………........................................................................................................………

Pengkajian Dilakukan Tanggal................jam................WIB

I. IDENTITAS
Inisial Nama : …………………... Alamat : ….....................................................………
Tempat/tgl.lahir : …………………... Agama : ….....................................................………
Usia : …………………... Suku Bangsa : ….....................................................………

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 Nama Ayah/Ibu : ………….......…... Pendidikan ayah: ….....................................................………
Pekerjaan Ayah : ……..................... Pendidikan ibu : ….....................................................………
Pekerjaan Ibu : …………………...
Berat bayi :
Panjang Badan :

Apgar ScorE :

Usia Gestasi :
Berat Badan : Panjang Badan :
Indikasi persalinan :

Tidak ada ( ) Ada ( )

Aspirasi mekonium :

Denyut jantung janin abnormal ( )

Prolaps tali pusat/lilitan tali pusat ( )

Ketuban pecah dini ( ); beberapa jam :
Berat Ibu
Usia Gravida Partus Abortus

Persalinan:
Pervaginam ( )
Sectio caesarea ( ); Alasan :
Komplikasi kehamilan:

 Tidak ada ( ) Ada ( )

 Perawatan antenatal ( )
 Ruptur plasenta / plasenta previa ( )
 Pre eklampsia / toxcemia ( )
 Suspect sepsis ( )
 Persalinan premature/post matur ( )
 Masalah lain :
A. Pemeriksaan Fisik
Intruksi: Beri tanda cek () pada istilah yang tepat/ sesuai dengan data-data di bawah ini. Gambarkan
semua temuan abnormal secara objektif, gunakan kolom data tambahan bila perlu.

SISTEM PERSEPSI SENSORI

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 1. Kepala
a. Fontanel anterior Lunak ( ) Tegas ( )Datar ( ) Menonjol ( )
Cekung ( )
b. Sutura sagitalis:Tepat ( ) Terpisah ( ) Menjauh ( )Tumpang tindih ( )
c. Gambaran wajah Simetris ( )Asimetris ( )
d. Molding ( ) Caput succedaneum ( ) Cephalhematoma ( )

2. Mata
Bersih ( ) Sekresi ( )
Jarak interkantus Sklera: Putih ( ) ikterik ( )

5. Bibir
a. Bibir : normal ( ) sumbing ( )
b. Sumbing langit-langit/palatum ( )

6.Telinga, Hidung, Tenggorok

a. Telinga: Normal ( )Abnormal ( ) Sekret( )
b. Hidung: Simetris ( )Asimetris ( ) Sekret ( ) Nafas cuping hidung ( )
c. Tenggorok: Tonsil( ), radang( )

Masalah Keperawatan:
1.............................................................................................................................................................................................
2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM RESPIRASI

7. Toraks
Simetris ( ) Retraksi dada ( ) Klavikula normal ( )

Paru-paru
a. Suara nafas kanan kiri sama ( ) Tidak sama ( )
b. Suara nafas bersih ( ) ronchi ( ) sekresi ( )
wheezing ( ) vesikuler ( )tidak spontan ( )
c. Respirasi spontan ( ) Tidak spontan ( )

Alat bantu nafas:

( )Nasal kanul
( )O2 / incubator
Konsentrasi O2 : ltr/menit

Masalah Keperawatan:
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2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM KARDIOVASKULER
Jantung
Inspeksi: ictus cordis/denyut apeks( ), normal( ) melebar( )
Palpasi: kardiomegali( )

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 Perkusi: redup( ), pekak( )
Auskultasi: HR...............x/mnt. Aritmia( ),Disritmia( ) , Murmur ( )
Masalah Keperawatan:
1.............................................................................................................................................................................................
2.............................................................................................................................................................................................
3.............................................................................................................................................................................................

SISTEM PENCERNAAN
Mulut
Trismus ( ), Halitosis ( )
Bibir: lembab( ), pucat( ), sianosis( ), labio/palatoskizis( ), stomatitis( )
Gusi: ( ), plak putih( ), lesi( )
Gigi: Normal( ), Ompong( ), Caries( ), Jumlah gigi:...................
Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
Kebutuhan Nutrisi dan Cairan
BB sebelum sakit: kg BB sakit: kg
Makanan yang disukai:..........................
Selera makan:...........................
Alat makan yang digunakan:........................
Pola makan( x/ hari):......................
Porsi makan yang dihabiskan:............................
Pola Minum .............................gelas/hari) jenis air minum:.....................................................

Abdomen
Inspeksi : Bentuk: simetris( ), tidak simetris( ), kembung( ), asites( ),
Palpasi : massa ( ), nyeri ( )
Kuadran I :
Kuadran II :
Kuadran III :
Kuadran IV :
Auskultasi : bising usus........................x/mnt
Perkusi : Timpani ( ), redup ( )

BAB : warna........................................Frekuensi................................x/hari
Konsisitensi:.................................... lendir ( ), darah ( ), ampas ( )
Konstipasi ( )
Masalah Keperawatan:

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1.............................................................................................................................................................................................
2.............................................................................................................................................................................................
3.............................................................................................................................................................................................
SISTEM REPRODUKSI
Genitalia dan Anus
Laki-laki
Penis: normal/ada ( ), Abnormal…………………,
Scrotum dan testis: normal( ), hernia( ), hidrokel( )
Anus ; normal/ada ( ), atresia ani( )
Perempuan
Vagina: sekret( ), warna( )
Anus: normal/ada ( ), atresia ani( )
Masalah Keperawatan:
1.............................................................................................................................................................................................
2.............................................................................................................................................................................................
3............................................................................................................................................................................................
SISTEM MUSKULO SKELETAL
Reflek
Moro :
Mengisap :
Rooting :
Dan lain-lain:........................................................................................................................................................

ROM:

Tonus/aktifitas
a. Aktif ( ) Tenang ( ) Letargi ( ) Kejang ( )
b. Menagis keras ( ) lemah ( ) melengking ( )
Sulit menangis ( )
Ekstremitas
Amelia ( ), Sindaktili ( ), Polidaktili( )
Reflek Patologis :
Babinsky ...............................................................................................
Kernig ...................................................................................................
Brudzinsky.............................................................................................
Reflek Fisiologis:
Biceps.................................................................................................................
Triceps...............................................................................................................
Patella.................................................................................................................
Masalah Keperawatan:
1.............................................................................................................................................................................................

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2.............................................................................................................................................................................................
3.............................................................................................................................................................................................
SISTEM INTEGUMEN
Kulit
a. Warna Pink ( ) pucat ( ) Jaundice ( )
Sianosis pada kuku ( ) sirkumoral ( )
Periorbital ( ) seluruh tubuh ( )
b. Kemerahan (rash) ( )
c. Tanda lahir: ( ); sebutkan:
d. Turgor kulit: elastis ( ) tidak elastis ( ) edema ( ) Lanugo ( )
Suhu
a. Lingkungan
Penghangat radian ( ) Pengaturan suhu ( )
Inkubator ( ) Suhu ruang ( ) Boks terbuka ( )

Masalah Keperawatan:
1.............................................................................................................................................................................................
2.............................................................................................................................................................................................
3.............................................................................................................................................................................................
HUBUNGAN PERAN
Struktur keluarga (genogram tiga generasi) :

Budaya : ________________________________
Suku : ________________________________
Agama : ________________________________
Bahasa Utama : ________________________________
Perencanaan makanan bayi : ________________________________
Masalah sosial yang penting : ________________________________
Hubungan orang tua dan bayi : ________________________________

- Orang terdekat yang dapat dihubungi:

- Orang tua berespon terhadap penyakit: ya ( ) tidak ( )
Respon:
- Orang tua berespon terhadap hospitalisasi: ya ( ) tidak ( )
Respon:

- Riwayat anak lain:

Jenis kelamin anak Riwayat persalinan Riwayat imunisasi

TERAPI

Terapi Cara Pemberian Dosis Golongan / Jenis Indikasi

19
PEMERIKSAAN PENUNJANG

Tanggal Pemeriksaan

ANALISA DATA

DATA KLIEN Etiologi Masalah Keperawatan

DS : PATOFLOW

DO :

PRIORITAS MASALAH KEPERAWATAN

1……………………………………………………….
2……………………………………………………….
3……………………………………………………….

DIAGNOSA KEPERAWATAN
1………………berhubungan dengan……,...
2 Risiko………faktor risiko…………………...
3……………………………………………………….

RENCANA KEPERAWATAN

Nama Pasien : Diagnosa Medis :

Jenis kelamin : Hari/Tanggal :
No.Kamar/Bed : Shift :

No Dx. Keperawatan Tujuan (NOC) Intervensi (NIC)

1 .............berhubungan Setealah dilakukan tindakan Label NIC : .....................

dengan............ditandai keperawatan...x24 jam, pasien diharapkan 1. Monitor / kaji
dengan : menunjukkan perbaikan “..............(Label 2.Tindakan mandiri
DS : NOC) dengan kriteria hasil : perawat
DO : Indikator Awal Tujuan 3.Penkes pasien /
1. keluarga
2. 4.Kolaborasi dengan
20
 tim medis lain
(Dokter/ahli gizi/
3.
fisioterapi)

...........faktor
risiko........ditandai
2 dengan.....
DS:
DO

IMPLEMENTASI KEPERAWATAN

Nama Pasien : Diagnosa Medis :

Jenis kelamin : Hari/Tanggal :
No.Kamar/Bed : Shift :
Nama &
Dx. Tanggal& Implementasi keperawatan Respons TT
Keperawatan Waktu Perawat

EVALUASI KEPERAWATAN

Nama Pasien : Diagnosa Medis :

Jenis kelamin : Hari/Tanggal :
No.Kamar/Bed : Shift :

Dx. Tanggal & Evaluasi

Keperawatan Jam Paraf
S :

O:

A:

21
 Indikator Awal Sekarang Tujuan
1.
2.
3.

P :

22
23