PROGRAM STUDI PENDIDIKAN PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN SATRIA BHAKTI NGANJUK

Jl. Panglima Sudirman V Nganjuk (0358) 326110

FORMAT PENGKAJIAN PEDIATRIK

Data diambil tanggal : .............................................

Ruang rawat/kelas Jam : ....................................
No. Rekam medik : ................................................
: ................................................
I. Identitas Anak II. Identitas Orangtua
Nama Nama Ayah

: :
Tanggal lahir Nama Ibu

: :
Jenis kelamin Pekerjaan Ayah/Ibu :
Pendidikan Ayah/Ibu :
: Agama
II. Riwayat Keperawatan
Tanggal MRS
1. Riwayat Keperawatan Sekarang :
: a. Keluhan Utama : ........................................................................................
Suku Bangsa
b. Riwayat Penyakit saat ini : ........................................................................................
Alamat
............................................................................................................................................................
:
: ..............................................................................................................
Alamat
Diagnosa Medis
2. Riwayat Keperawatan Sebelumnya :
a. Riwayat
: Sumber Informasi Kesehatan masa lalu : ............................................................................
............................................................................................................................................................
: .........................................................................................................
b. Riwayat Persalinan
1). Prenatal : ....................................................................................................
....................................................................................................
....................................................................................................
2). Natal : ....................................................................................................
...................................................................................................
3). Post Natal :
Neonatus : …………………………………………………
………………………………………………….
Infant ( 1 bulan – 1 tahun ) : …………………………………………………
Toddler ( 1 – 3 tahun ) : …………………………………………………
Prasekolah ( 4 – 6 tahun ) : …………………………………………………
Sekolah ( 7 – 12 tahun ) : …………………………………………………
Imunisasi
- Hepatitis
B ............................................................................................................
-
BCG ......................................................................................................................
-
DPT .......................................................................................................................
-
Polio ......................................................................................................................
-
Campak .................................................................................................................

3. Riwayat Kesehatan
keluarga
a. Penyakit yang pernah/masih diderita oleh anggota
keluarga :....................................
4. Riwayat Pertumbuhan dan Perkembangan
a. Pertumbuhan
- Berat badan ..........................................................................................................
- Panjang badan ......................................................................................................
- Lingkar kepala ......................................................................................................
- Lingkar lengan atas ...............................................................................................
- Lingkar dada .........................................................................................................

b. Perkembangan
- Motorik kasar ........................................................................................................
- Motorik halus ........................................................................................................
- Sosial ....................................................................................................................
- Bahasa ...................................................................................................................

c. Tahap perkembangan
- Psikososial ............................................................................................................
- Psikoseksual ..........................................................................................................
- Kognitif..................................................................................................................

5. Spiritual
a. Anak ...........................................................................................................................
b. Orangtua ....................................................................................................................

6. Pengetahuan keluarga
............................................................................................................................................................
................................................................................................................

7. Kebutuhan dasar neonatus / anak

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

III. Pola Aktivitas sehari –

hari
1. Pola istirahat dan tidur
a.
Istirahat ......................
....................................
....................................
............
b. Tidur

Frekwensi ..............
...............................
...............................
...................

jumlah jam
tidur .......................
...............................
...............................
...
 masalah tidur .............................................................................................
2. Pola
aktivitas .......................................................................................................
3. Pola nutrisi
a. Makan (frelwensi, porsi, komposisi,
diet) .....................................................
b. Minum (jumlah, jenis,jadwal)........................................................................
 2. Kepala .................................................................................................................
3. Mata .....................................................................................................................
4. Telinga .................................................................................................................
5. Hidung .................................................................................................................
6. Mulut ...................................................................................................................
7. Leher ....................................................................................................................
8. Dada .....................................................................................................................
9. Abdomen .............................................................................................................
10. Lengan .................................................................................................................
11. Punggung .............................................................................................................
12. Genetalia ..............................................................................................................
13. Pinggul, bokong, dan anus ..................................................................................
14. Neurologis
a. Reflek fisiologis ............................................................................................
b. Reflek patologis .............................................................................................
c. Saraf otak (N. Neurologia) ............................................................................

V. Pemeriksaan penunjang / tes diagnostik

a. Laboratorium .......................................................................................................
b. Foto roxen ............................................................................................................
c. USG .....................................................................................................................
d. ECG .....................................................................................................................

VI. Terapi Medis

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

Nganjuk, ...............................2022
Mahasiswa

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