I. BIODATA
Identintas Anak Identitas Orang Tua
Nama/nama panggilan : Nama ayah/ibu :
Tanggal lahir : Usia ayah/ibu :
Jenis kelamin : Pekerjaan ayah/ibu :
Agama : Agama ayah/ibu :
Pendidikan : Pendidikan ayah/ibu :
Alamat : Alamat ayah/ibu :
Tanggal MRS : Suku bangsa :
Tanggal Pengkajian :
Dx Medis :
Sumber Informasi :
Identitas Saudara Kandung
No Nama Usia Hubungan Status Kesehatan
2. Natal
1. Tempat Melahirkan : RS Klinik Rumah
2. Lama Persalinan ....................................................................................................
3. Jenis Persalinan .....................................................................................................
4. Penolong Persalinan ..............................................................................................
5. Komplikasi Persalinan ..........................................................................................
3. Post Natal
Kondisi bayi : PB :........cm, BB lahir............gram
Penyakit yang diderita setelah lahir :.....................................
c. Pola perubahan nutrisi tiap tahap usia sampai nutrisi saat ini
USIA Jenis Nutrisi Keluhan
0-6 bulan
6-12 bulan
Saat ini
5. Sistem Kardiovaskuler
a. Nyeri dada : Ada Tidak ada
b. Irama jantung.............................................................................................................
c. Pulsasi........................................................................................................................
d. Bunyi jantung............................................................................................................
e. CRT.............detik
f. Cyanosis : Ya Tidak
g. Clubbing finger : Ada Tidak
h. Lain-lain....................................................................................................................
6. Sistem Persyarafan
a. Kesadaran..................................................................................................................
b. GCS...........................................................................................................................
c. Reflek-reflek :
Suckling Ada Tidak
Menggegam Ada Tidak
Babinsky Ada Tidak
Moro Ada Tidak
Patella Ada Tidak
d. Kejang : Ada Tidak
Jenis...........................................................................................................................
e. Kaku kuduk Ada Tidak
f. Nyeri kepala Ada Tidak
g. Istirahat tidur : Siang :...............................................................................................
Malam :.........................................................................................................
Kebiasaan sebelum tidur :.........................................................................................
Kesulitan tidur :.........................................................................................................
h. Kelainan nervus cranialis..........................................................................................
i. Lain-lain....................................................................................................................
7. Sistem Genitourinaria
a. Bentuk alat kelamin....................................................................................................
b. Uretra..........................................................................................................................
c. Kebersihan alat kelamin.............................................................................................
Frekuensi berkemih......x/hr, warna..............., bau............
Produksi urin.........ml/hr
Tempat yang digunakan............................................................................................
Masalah eliminasi urine.............................................................................................
d. Lain-lain....................................................................................................................
8. Sistem Pencernaan
a. Mulut
Mukosa ...................................................................................................................
Bibir: Normal Labiokisis Palatokisis
Lidah .......................................................................................................................
Kebersihan rongga mulut .......................................................................................
Kebiasaan gosok gigi ..............................................................................................
Keadaan gigi : bersih kotor ada caries tidak ada caries
b. Tenggorokan : kesulitan menelan tidak ada kesulitan kemerahan
Pembesaran tonsil
c. Abdomen
Nyeri tekan : lokasi.............................., peristaltic..............x/mnt
Buang Air Besar.............x/hr, konsisten.............., warna............., bau......................
Tempat yang biasa digunakan ................................................................................
Masalah eliminasi alvi................................................................................................
Pemakaian obat pencahar...........................................................................................
Lain-lain....................................................................................................................
XII. TERAPI
Mahasiswa
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