JURUSAN KEPERAWATAN

FAKULTAS ILMU KESEHATAN

UNIVERSITAS TRIBHUWANA TUNGGADEWI

PENGKAJIAN KEPERAWATAN ANAK

Nama Mahasiswa : Tempat Praktik :
NIM : Tgl. Praktik :

A. PENGKAJIAN
1. Pengumpulan Data
a. Biodata
1) Nama :
2) No Register :................................................................................................................
3) Jenis Kelamin : ................................................................................................................
4) Umur :
5) Status Perkawinan:..................................................................................................................
6) Pekerjaan : ................................................................................................................
7) Agama :
8) Pendidikan Terakhir :..............................................................................................................
9) Alamat :
10)Tanggal MRS : ................................................................................................................
11)Tanggal pengkajian:................................................................................................................
b. Diagnosa Medis : ................................................................................................................
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c. Keluhan Utama : Saat Pengkajian, saat MRS
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d. Riwayat Penyakit Sekarang
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e. Riwayat Kesehatan/Penyakit Yang Lalu

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f. Riwayat Kesehatan Keluarga
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g. Riwayat Tumbuh Kembang
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h. Riwayat Imunisasi
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i. Riwayat persalinan
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j. Pola Aktivitas Sehari-hari

1) Makan dan minum
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2) Pola eliminasi
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3) Pola istirahat dan tidur
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4) Kebersihan diri
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k. Riwayat Psikologis
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l. Pemeriksaan Fisik
1) Keadaan umum:.........................................................................................................................
2) Tanda vital :
3) Pemeriksaan kepala leher
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4) Pemeriksaan integumen
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 5) Data dan thorax
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6) Payudara
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7) Abdomen
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8) Genetalia
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9) Ekstrimitas
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m. Pemeriksaan Neurologis
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n. Pemeriksaan Penunjang
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Terapi/Pengobatan/penatalaksanaan
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Malang, …………….
Perawat
 ANALISA DATA

Nama Pasien :
Umur :
No. Register :

DATA PENUNJANG ETIOLOGI MASALAH

KEPERAWATAN
 DIAGNOSA KEPERAWATAN

Ruang :
Nama Pasien :
No. Register :
 DAFTAR MASALAH KEPERAWATAN
Ruang :
Nama Pasien :
No. Register :

No. Tanggal Tanggal Teratasi Tanda Tangan

Diagnosa Keperawatan
DX Muncul
 RENCANA ASUHAN KEPERAWATAN
Nama Klien :
No. Reg. :

No. Diagnosa Tujuan

Tanggal Intervensi TT
DX Keperawatan Kriteria Standart
 CATATAN KEPERAWATAN
(Minimal 2 hari, semua diagnosa)
Ruang :
Nama Pasien :
Umur :
No. Register :

TANDA
NO. TANGGAL NO. DX. KEP TINDAKAN
TANGAN
 EVALUASI

Nama :
Umum : No. Register :

No. DX. Kep. Tanggal Tanggal Tanggal Tanggal

S : S : S : S :

O : O : O : O :

A : A : A : A :

P : P : P : P :
 Resume
(R….)

RENCANA ASUHAN KEPERAWATAN

Nama Klien : Tgl MRS :

Diadnosa medis : Tgl Pengkajiaan :
No. Reg. :

Subjective Obyektive Analisis Planniang Implementasi Evaluation TT

S:
O:
Theraphy A:
Data P:
Penunjang