FORMAT PENGKAJIAN

ASUHAN KEPERAWATAN PADA ANAK

DI RS SYUHADA HAJI BLITAR
__________________________________

Disusun Oleh

NAMA : RIZKY NURIS SYAFRIANI

NIM : P17230213089

KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN MALANG
JURUSAN KEPERAWATAN
PODI D3 KEPERAWATAN BLITAR

1
 FORMAT PENGKAJIAN PADA ANAK

A. PENGKAJIAN

1. PENGUMPULAN DATA

Tanggal : ________________________
I. Identitas Data
Nama : ________________ Alamat : ________________

Tanggal Lahir : ________________ No. Telp : ________________

Umur : ________________ Kultur : ________________

Nama Ayah/Ibu : ________________ Agama : ________________

Pekerjaan Ayah : ________________ Pendidikan : ________________

Pekerjaan Ibu : ________________ Anak Ke : ________________

II. Alasan Kunjungan / Keluhan Utama :

________________________________________________________________
________________________________________________________________
________________________________________________________________

III. Riwayat Penyakit Sekarang

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
IV. Riwayat Kehamilan dan Kelahiran.
a. Prenatal :
_______________________________________________________________
_______________________________________________________________
b. Natal :
_______________________________________________________________
_______________________________________________________________

c. Postnatal :
______________________________________________________________
______________________________________________________________
V. Riwayat Masa Lampau.
a. Penyakit-penyakit waktu kecil
_____________________________________________________________
b. Pernah dirawat di rumah sakit
_____________________________________________________________
c. Obat-obatan
_____________________________________________________________
d. Tindakan (misalnya : operasi)
_____________________________________________________________
e. Allergi
_____________________________________________________________
f. Kecelakaan
_____________________________________________________________
g. Imunisasi
_____________________________________________________________
VI. Riwayat Keluarga
________________________________________________________________
________________________________________________________________
________________________________________________________________
_______________________________________________________________
VII. Riwayat Sosial
a. Yang mengasuh
_______________________________________________________________
b. Hubungan dengan anggota keluarga
_______________________________________________________________
c. Hubungan dengan teman sebaya
_______________________________________________________________
d. Pembawaan secara umum
_______________________________________________________________
e. Lingkungan rumah
_______________________________________________________________

VIII. Kebutuhan Dasar

a. Cairan
_______________________________________________________________
b. Makanan
_______________________________________________________________
c. Pola tidur
_______________________________________________________________
d. Mandi
_______________________________________________________________
e. Aktifitas / bermain
_______________________________________________________________
f. Eliminasi
_______________________________________________________________
IX. Keadaan Kesehatan saat ini.
a. Diagnosa medis
_______________________________________________________________
b. Tindakan operasi
_______________________________________________________________
c. Status nutrisi
_______________________________________________________________
d. Status cairan
_______________________________________________________________
e. Obat-obatan
_______________________________________________________________
f. Aktifitas
_______________________________________________________________
g. Tindakan keperawatan
_______________________________________________________________
h. X – ray
_______________________________________________________________
i. Lain-lain
_______________________________________________________________

X. Pemeriksaan fisik
a. Keadaan Umum :
______________________________________________________________
b. Tanda Vital :
______________________________________________________________
c. Pemeriksaan kepala leher :
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
d. Pemeriksaan integumen :
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

e. Dada dan thorax :

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

f. Payudara :
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

g. Abdomen :
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

h. Genetalia :
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
 i. Ekstrimitas :
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

XI. Pemeriksaan tingkat perkembangan (sesuai usia)

a. Motor kasar
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
b. Motor halus
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
c. Adaptasi Sosial
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
d. Bahasa
____________________________________________________________
____________________________________________________________
____________________________________________________________
XI. Informasi lain
________________________________________________________________
________________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
XII PEMERIKSAAN PENUNJANG/DIAGNOSTIK

1. Laboratorium :

2. Rontgen :

3. ECG :

4. USG :

5. Lain-lain :

Blitar, …………………………2023

Nama Mahasiswa

( _______________________ )
 ANALISA DATA

Nama Pasien :

Umur :

No. Register :

Tanggal Data Penunjang Masalah Etiologi

S:

O:

P:
 DIAGNOSA KEPERAWATAN

Nama Pasien :

Umur :

No. Register :

No. Diagnosis Keperawatan Ditemukan Masalah Masalah Selesai

Tanggal Paraf Tanggal Paraf

 PRIORITAS DIAGNOSA KEPERAWATAN

Nama Pasien :

Usia :

No. Register :

No. TANGGAL DIAGNOSA KEPERAWATAN TANDA

TANGAN
 PERENCANAAN KEPERAWATAN

Nama Pasien :

Usia :

No. Reg :

Intervensi
Diagnosa
No. Hari/ Tanggal Tujuan dan
Keperawatan Tindakan Keperawatan Rasional
Kriteria Hasil
 IMPLEMENTASI KEPERAWATAN

Nama Pasien :

Umur :

No. Register :

Tanggal/Jam No. Dx. Tindakan keperawatan Respon Pasien Tanda

Kep Tangan
 EVALUASI KEPERAWATAN (FORMATIF)

Nama :

Usia :
No. Register :

No. Dx. Kep. Tanggal Tanggal Tanggal

S : S : S :

O : O :

A : A : A :

P : P : P :