Lampiran 1 Format Pengkajian

FORMAT PENGKAJIAN ANAK

Tanggal Pengkajian : jam :

Tanggal dirawat :
Sumber data/informasi :

DATA IDENTITAS KLIEN

Nama : ................................................................................
Tempat / Tanggal lahir/ Umur: ........................................................................
Jenis Kelamin (P/L*) :.........................................................................
Nama Ayah/lbu : ........................................................................
Usia ayah/ibu : .......................................................................
Pekerjaan Ayah : ...............................................................................
Pendidikan Ayah : ...............................................................................
Pekerjaan lbu : ...............................................................................
Pendidikan Ibu : ...............................................................................
Alamat : ........................................................................
Kultur : ........................................................................
Agama : ...............................................................................
Diagnosis Medis : ...............................................................................

I. KELUHAN UTAMA
a. Keluhan Masuk Rumah Sakit/Alasan Masuk Rumah Sakit
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
b. Keluhan Saat ini
...............................................................................................................................
...............................................................................................................................
..............................................................................................................................
II. RIWAYAT KESEHATAN
a. Riwayat kesehatan sekarang:
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
51
 .............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
b. Riwayat Kesehatan Dahulu (prenatal, perinatal, postnatal, alergi, pengobatan,
cedera, hospitalisasi, tindakan operasi)
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
c. Riwayat Kesehatan Keluarga (sosial ekonomi, penyakit keluarga)
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
d. Riwayat Kehamilan dan Persalinan (data khusus pada pasien bayi)
Pre natal
(kunjungan ke bidan/dokter, penkes yang sudah didapatkan, HPHT, kenaikan
BB saat hamil, komplikasi kehamilan, obat, riwayat hospitalisasi, dll)
..............................................................................................................................
..............................................................................................................................
...........................................................................................................................
Natal
(lama persalinan, komplikasi persalinan, jenis persalinan, tempat melahirkan,
penolong persalinan)
.............................................................................................................................
..............................................................................................................................
............................................................................................................................
Post natal
(alat bantu napas, ada tidaknya trauma lahir, skor APGAR, obat, interaksi
orang tua dan bayi, respon fisiologis atau perilaku bermakna, dll)
.............................................................................................................................

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
52
 ..............................................................................................................................
............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
Riwayat Ibu (G…P…A…)

e. Riwayat Imunisasi (dasar, ulangan)

..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
f. Riwayat Pertumbuhan dan Perkembangan
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
g. Riwayat Sosial dan Lingkungan (sistem pendukung/keluarga terdekat yang
dapat dihubungi. Lingkungan rumah, problem sosial yang penting, budaya
dalam keluarga dan lingkungan, Bahasa yang digunakan, dll)
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
h. Perencanaan makan bayi (data untuk pasien bayi)
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
i. Hubungan orang tua (ayah/ibu) dan bayi (data untuk pasien bayi)
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
53
 j. Riwayat anak lain (data untuk pasien bayi)
Jenis Kelamin anak Riwayat Persalinan Riwayat Imunisasi

k. Sumber pendapatan keluarga

..............................................................................................................................
..............................................................................................................................
..............................................................................................................................

GENOGRAM (3 generasi)

Keterangan:

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

Masalah Keperawatan dari data Riwayat :

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
54
 III. KEADAAN KESEHATAN SAAT INI
1. Status Nutrisi dan Cairan (bandingkan saat sakit dan sebelum sakit)
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
Pengkajian Mual dan Muntah

.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
2. Eliminasi (frekuensi BAK/BAB, karakteristik urine, karakteristik feses,
penggunaan alat bantu, dll) bandingkan saat sakit dan sebelum sakit
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
3. Aktivitas Bermain Anak (bandingkan saat sakit dan sebelum sakit)
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
4. Kebutuhan Istirahat dan Tidur (bandingkan saat sakit dan sebelum sakit)
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
55
 .............................................................................................................................
.............................................................................................................................
5. Kebersihan Diri (bandingkan saat sakit dan sebelum sakit)
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
6. Obat-Obatan
No Obat Dosis Indikasi
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................
.......................................... ................................ ....................................................

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
56
 7. Hasil Laboratorium
Pemeriksaan Hasil Nilai Normal Satuan

8. Pemeriksaan Penunjang Lainnya

Masalah Keperawatan Data Keadaan Kesehatan saat ini :

IV. PEMERIKSAAN FISIK (Inspeksi, Palpasi, Perkusi, Auskultasi)

1. Keadaan Umum:
..........................................................................................................................
..........................................................................................................................
2. Kesadaran : ..............................................................................................
− Tanda Vital : ..............................................................................................
− Nadi : x/ menit - RR : x/menit
− Suhu : °C SpO2 :
− Data lainnya :
− Data khusus bayi:
Penggunaan: inkubator/penghangat radian/boks terbuka*)

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
57
 3. Pengukuran BB, PB/TB, LK, LLA, lingkar perut, lingkar dada (khusus
pasien bayi bandingkan saat lahir dan saat dirawat)

4. Pengkajian Skala Nyeri (sesuaikan usia dan boleh menggunakan selain yang
tertera)

..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
5. Kepala, Leher dan Wajah
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
58
 Data khusus bayi:
Fontanel anterior (lunak/tegas/datar/menonjol*)
Sutura sagitalis (terpisah/tepat/menjauh/tumpeng tindih*)
Gambar wajah (simetris/tidak simetris*)
Molding (caput succedaneum/cephal hematoma*)
Adanya kelainan (bibir sumbing/sumbing palatum*)

6. Mata (posisi bola mata, Gerakan mata, konjungtiva, kornea, sklera, pupil,
tajam penglihatan, dll)
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
.........................................................................................................................
Data khusus bayi:
Warna (bersih/sekresi/jaundice*)
Jarak interkantus ………
7. THT
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
................................................ ..............................................................................
Data khusus bayi:
Tongue tie…… kelainan lain………………………….
8. Ekstremitas
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
.........................................................................................................................
9. Integritas Kulit
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
59
 Data khusus bayi: ada tanda lahir/kemerahan/lanugo/jaundice/sianosis
periorbital/sianosis seluruh tubuh*)
10. Dada, Toraks, Jantung
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

11. Abdomen
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
.....................................................................................................................................
Data khusus bayi: umbilikus (normal/abnormal/inflamasi/drainase*)
12. Genitalia
.......................................................................................................................
...........................................................................................................................
...........................................................................................................................
Data khusus bayi:
Anus (paten/imperforata*)
Alat kelamin (normal/abnormal*)

Masalah Keperawatan data Pemeriksaan Fisik:

V. TUMBUH KEMBANG SAAT INI

..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
60
 ..........................................................................................................................
………………………………………………………………………………..
………………………………………………………………………………..
Kesimpulan Status Gizi (grafik lampirkan)
BB/U…………………………………………………………………………
TB/U…………………………………………………………………………
BB/TB……………………………………………………………………….
CDC ………………………………………………………………………….

Kesimpulan Perkembangan

Masalah Keperawatan Tumbuh Kembang Saat ini:

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
61
 ANALISIS DATA
Nama Klien : ..............................................
Umur : ..............................................
Ruangan/Kamar : ..............................................
No. RM : ..............................................
No. Data Penyebab Masalah

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
62
 PRIORITAS MASALAH

Nama klien : ..............................................

Umur : ..............................................
Ruangan/kamar : ..............................................
No. RM : ..............................................
Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama Perawat)

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
63
 RENCANA KEPERAWATAN

Nama Klien : ..............................................

Umur : ..............................................
Ruangan/Kamar : ..............................................
No. RM : ..............................................
Tujuan Dan
No. Diagnosa Keperawatan Intervensi Rasional
Kriteria Hasil

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
64
 IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN

Nama Klien : ..............................................

Umur : ..............................................
Ruangan/Kamar : ..............................................
No. RM : ..............................................
No.
Waktu Waktu
Dx Implementasi TT Evaluasi TT
Tgl/jam Tgl/jam
Kep

Pedoman Pembimbingan Preseptor Kurikulum KPT berdasarkan KKNI Program Profesi Ners
Program Studi Ilmu Keperawatan FK ULM
65