FORMAT PENGKAJIAN

A. PENGKAJIAN

A1. PENGUMPULAN DATA

I. BIODATA

IDENTITAS ANAK IDENTITAS BAPAK

Nama :..................................... Nama :.....................................
No. Register :..................................... Umur :.....................................
Umur (bln, hr) :..................................... Jenis kelamin :.....................................
Jenis kelamin :..................................... Alamat :.....................................
Alamat :..................................... Pendidikan :.....................................
Suku bangsa :..................................... Pekerjaan :.....................................
Tanggal lahir/Umur :..................................... Suku bangsa :.....................................
Tgl MRS :..................................... No. Tlp/HP
Tanggal pengkajian :..................................... :.....................................
Diagnosa medis :..................................... IDENTITAS IBU :.....................................
Urutan anak :.....................................
Nama :.....................................
Umur :.....................................
Jenis kelamin :.....................................
Alamat :.....................................
Pendidikan :.....................................
Pekerjaan :.....................................
Suku bangsa :.....................................
No. Tlp/HP :.....................................

II. KELUHAN UTAMA/ALASAN KUNJUNGAN

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III. RIWAYAT KESEHATAN

A. RIWAYAT PENYAKIT SEKARANG
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 B. RIWAYAT KESEHATAN YANG LALU
1) Penyakit-penyakit waktu kecil _______________________________________________
2) Pernah dirawat di rumah sakit ______________________________________________
3) Obat-obatan ____________________________________________________________
4) Tindakan (misalnya : operasi) _______________________________________________
5) Allergi _________________________________________________________________
6) Kecelakaan ____________________________________________________________
7) Imunisasi ______________________________________________________________

C. RIWAYAT TUMBUH KEMBANG

a. Prenatal ____________________________________________________________
____________________________________________________________________
b. Intranatal ___________________________________________________________
____________________________________________________________________
c. Post natal ___________________________________________________________
____________________________________________________________________
IV. Riwayat Keluarga
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
V. Riwayat Sosial
a. Yang mengasuh ________________________________________________________
b. Hubungan dengan anggota keluarga ________________________________________
c. Hubungan dengan teman sebaya ___________________________________________
d. Pembawaan secara umum ________________________________________________
e. Lingkungan rumah ______________________________________________________

VI. PEMERIKSAAN FISIK (HEAD TO TOE)

A. Keadaan Umum
Postur: .........................................................................................................................
Kesadaran: .................................................................................................................
B. Kepala dan rambut
Kebersihan : ...............................................................................................................
Bentuk kepala : ..........................................................................................................
Keadaan rambut :........................................................................................................
Keadaan kulit kepala : caput succedanum, cefalohematom: ....................................
Fontanela anterior : lunak/menonjol/tegas/cekung/datar: ........................................

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 Sutura sagitalis : tepat/terpisah/menjauh: .................................................................
Distribusi rambut : merata/tidak merata: ....................................................................
C. Mata
Kebersihan : ..................................................................................................................
Pandangan : .................................................................................................................
Sclera : ..........................................................................................................................
Conjungtiva : .................................................................................................................
Pupil : .............................................................................................................................
Gerakan bola mata : .....................................................................................................
Sekret: ............................................................................................................................
D. Hidung
Pernafasan Cuping hidung : ..........................................................................................
Struktur :.........................................................................................................................
Kelainan lain : polip/perdarahan/peradangan: ...............................................................
Sekresi: ........................................................................................................................
E. Telinga
Kebersihan : .......................................................................................................................
Sekresi : .............................................................................................................................
Struktur : .............................................................................................................................
Fistulaaurikel: ....................................................................................................................
Membran timpani: ..............................................................................................................
F. Mulut dan Tengorokan
Jamur (stomatitis, moniliasis): ...........................................................................................
Kelaianan bibir dan rongga mulut (gnato/labio/palato skizis): ............................................
Problem menelan : .............................................................................................................
G. Leher
Venajugularis : ...................................................................................................................
Arteri karotis : .....................................................................................................................
Pembesaran tiroid dan limfe : ............................................................................................
Torticoliis: ..........................................................................................................................
H. Dada/Thorak (jantung dan Paru)
Bentuk dada: ......................................................................................................................
Pergerakan kedua dinding dada: ........................................................................................
Tarikan dinding dada ke atas/bawah: ..................................................................................
Suara pernafasan: ...............................................................................................................
Frekwensi nafas: .................................................................................................................
Abnormalitas suara nafas: ..................................................................................................

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 Suara jantung: ....................................................................................................................
I. Ekstremitas atas
Tonus otot: ..........................................................................................................................
CRT: ..................................................................................................................................
Trauma, deformitas: ..........................................................................................................
Kelainan struktur: ................................................................................................................
J. Perut
Bentuk perut: ......................................................................................................................
Bising usus: .........................................................................................................................
Ascites:..............................................................................................................................
Massa: ...............................................................................................................................
Turgor kulit: .......................................................................................................................
Vena: ..............................................................................................................................
Hepar: ..............................................................................................................................
Lien: .......................................................................................................................
Distensi: ............................................................................................................................
K. Punggung
Spina bifida: ........................................................................................................................
Deformitas: ........................................................................................................................
Kelainan struktur: ................................................................................................................
L. Kelamin dan anus
Keadaan kelamin luar (kebersihan, lesi, kelainan) : ..........................................................
............................................................................................................................................
Anus : ...............................................................................................................................
Kelainan: ........................................................................................................................
M. Ekstremitas bawah
Tonus otot: .........................................................................................................................
Trauma, deformitas: ..........................................................................................................
Kelainan struktur: ..............................................................................................................
N. Integumen
Warna kulit: ......................................................................................................................
Kelembaban: .....................................................................................................................
Lesi: ..................................................................................................................................
Warna kuku : ....................................................................................................................
Kelainan: ..........................................................................................................................
VII. PENGUKURAN ANTROPOMETRI
Berat badan: ..........................................................................................................................

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 Panjang/Tinggi badan: .............................................................................................................
Lingkar kepala: ......................................................................................................................
Lingkar dada: ..........................................................................................................................
Lingkar lengan Atas: ............................................................................................................
Kesimpulan Status gizi: Baik, kurus, Sangat kurus, Gemuk, Sangat gemuk (lingkari salah
satu)

VIII. RIWAYAT IMUNISASI

Sebutkan imunisasi yang sudah diberikan beserta umur saat diimunisasi
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IX. PEMENUHAN KEBUTUHAN DASAR

A. OKSIGEN
Kebutuhan oksigen: ..........................................................................................................
Dosis oksigen: ...................................................................................................................
Cara pemberian: ..........................................................................................................
B. CAIRAN:
Kebutuhan cairan dalam 24 jam: .....................................................................................
Jenis cairan yang diberikan: ...........................................................................................
Cara/rute pemberian: .......................................................................................................
Balance cairan dalam 24 jam:
Intake: ..............................................................................................................................
Output : ............................................................................................................................
IWL: ..............................................................................................................................
Kesimpulan: ..................................................................................................................
C. Nutrisi:
Kebutuhan kalori: ............................................................................................................
Bentuk/jenis nutrisi yang diberikan: ....................................................................................
Cara pemberian: .............................................................................................................
Frekwensi pemberian: ..................................................................................................
Alergi/Pantangan: .............................................................................................................
Nafsu makan: .............................................................................................................

D. ELIMINASI URINE
Volume urine:..................................................................................................................
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 Warna:............................................................................................................................
Frekwensi:.........................................................................................................................
Cara BAK (spontan/kateter):............................................................................................
Kelaianan pemenuhan BAK: ............................................................................................

E. ELIMINASI ALVI
Volume feses:...................................................................................................................
Warna feses:....................................................................................................................
Konsistensi: ....................................................................................................................
Frekwensi:.........................................................................................................................
Darah, lendir dalam feses:................................................................................................
F. TIDUR
Jumlah jam tidur dalam 24 jam: .....................................................................................
Kualitas tidur (sering terbangun, rewel, tidak bisa tidur): ...............................................
G. PSIKOSOSIAL
Hubungan orangtua dengan anak: ......................................................................
Yang mengasuh: .........................................................................................................

X. TANDA-TANDA VITAL
a. Tekanan Darah : ............................................................................................................
b. Denyut Nadi :............................................................................................................
c. Pernafasan :............................................................................................................
d. Suhu Tubuh :............................................................................................................

XI. PEMERIKSAAN TINGKAT PERKEMBANGAN (KPSP/Denver)

Interpretasi perkembangan :
KPSP
Sesuai
Meragukan
Penyimpangan
(Lampirkan KPSP)

Denver
Normal
Suspect
Untestable
(Lampirkan formulir Denver)

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XII. DATA PENUNJANG
A. Radiologi
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

B. Laboratorium
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

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C. Pemeriksaan lainnya
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

Mengetahui, ...............................,.......................................
Pembimbing klinik
Mahasiswa

(.......................................................) (............................................................)
NIM.

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A2. ANALISIS DATA

HARI/TGL : ...............................................................................................

NO KEMUNGKINAN
DATA MASALAH
PENYEBAB

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B. DIAGNOSA KEPERAWATAN

NAMA & TANDA

NO TANGGAL DIAGNOSA KEPERAWATAN
TANGAN

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 C. RENCANA TINDAKAN KEPERAWATAN

DIAGNOSA NAMA & TANDA

NO TUJUAN DAN KRITERIA HASIL INTERVENSI
KEPERAWATAN TANGAN

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D. IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN

NAMA &
NO TANGGAL JAM TINDAKAN KEPERAWATAN TANDA
TANGAN

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 E. EVALUASI

DIAGNOSA TANGGAL
N KEPERAW
O
ATAN

S: S: S:
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O: O: O:
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 DIAGNOSA TANGGAL
N KEPERAW
O
ATAN
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A:
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P: ................................................. P:
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Mengetahui,
Pembimbing Akademik Pembimbing Lahan

(.......................................................) (……………………………….)

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