Format Pengkajian Anak
ASUHAN
KEPERAWATAN PADA An. ...............................
DENGAN
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Nama
Mahasiswa
NIM
Tanggal
Pegkajian
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I.
IDENTITAS
KLIEN
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Nama/Inisial
Umur
Tanggal
Lahir
Jenis
Kelamin
Agama
MRS
No.
Register
Diagnosa
Medis
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Penanggung
Jawab
Nama
Ayah/Ibu
Pekerjaan
Ayah/Ibu
Pendidikan
Ayah/Ibu
Umur
Ayah/Ibu
Suku
Ayah/Ibu
Agama
Alamat
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II.
KELUHAN
UTAMA
......................................................................................................................................................................................................................................................................................................................................................................
III.
RIWAYAT
PENYAKIT SEKARANG
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
IV.
RIWAYAT
KESEHATAN KELUARGA
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
V.
RIWAYAT
KEHAMILAN DAN KELAHIRAN
a.
Pre
natal
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
b.
Natal
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
c.
Post natal
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
VI.
RIWAYAT PENYAKIT MASA LALU
a.
Penyakit-penyakit
waktu kecil
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
b.
Pernah
dirawat di Rumah Sakit
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
c.
Penggunaan
obat-obatan
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
d.
Tindakan
(misal: operasi atau tindakan lain)
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
e.
Alergi
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
f.
Kecelakaan
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
g.
Imunisasi
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
VII. RIWAYAT PSIKOSOSIAL
a.
Genogram
b.
Yang
mengasuh anak
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
c.
Hubungan
dengan anggota keluarga
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
d.
Hubungan
dengan teman sebaya
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
e.
Pembawaan
umum
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
f.
Lingkungan
rumah
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
VIII.
KEBUTUHAN DASAR
a.
Makanan
yang disukai dan tidak disukai anak
Sebelum
sakit: .............................................................................................................................
Saat
sakit: ....................................................................................................................................
Selera:
Sebelum
sakit: .............................................................................................................................
Saat
sakit: ....................................................................................................................................
Alat
makan yang digunakan:
Sebelum
sakit: .............................................................................................................................
Saat
sakit: ....................................................................................................................................
Jam
makan
Sebelum
sakit: .............................................................................................................................
Saat
sakit: ....................................................................................................................................
b.
Pola
tidur
Kebiasaan-kebiasaan
sebelum tidur (apakah perlu mainan, dibacakan cerita, benda-benda yang dibawa
tidur):
Sebelum
sakit: .............................................................................................................................
Saat
sakit: ....................................................................................................................................
c.
Mandi
Sebelum
sakit: .............................................................................................................................
Saat
sakit: ....................................................................................................................................
d.
Aktivitas/bermain
Sebelum
sakit: .............................................................................................................................
Saat
sakit: ....................................................................................................................................
e.
Eliminasi
Sebelum
sakit: .............................................................................................................................
Saat
sakit: ....................................................................................................................................
IX.
KEADAAN KESEHATAN SAAT INI
a.
Diagnosa
Medis:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
b.
Tindakan
Operasi:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
c.
Status
Nutrisi:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
d.
Status
Cairan:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
e.
Obat-Obatan:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
f.
Aktifitas:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
X.
PEMERIKSAAN PENUNJANG
·
Hasil
Laboratorium: ........................................................................................................................................
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·
Pemeriksaan
lain-lain: ....................................................................................................................................
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
XI.
PEMERIKSAAN FISIK
a.
Keadaan
Umum
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Keadaan
Sakit :
................................................... Tinggi
Badan : .....................................................
Tekanan
Darah :
................................................... Berat
Badan :
.....................................................
Nadi :
................................................... Suhu :
......................................................
Respirasi :
...................................................
b.
Review
of System (ROS)
1.
Kepala
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2.
Muka
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3.
Mata
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4.
Telinga
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
5.
Hidung
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
6.
Mulut
dan Faring
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
7.
Leher
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
8.
Payudara
dan Ketiak
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9.
Thorax
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
10.
Paru-paru
Inspeksi
..........................................................................................................................................................................................................................................................................................................................................
Palpasi
..........................................................................................................................................................................................................................................................................................................................................
Auskultasi
..........................................................................................................................................................................................................................................................................................................................................
Perkusi
..........................................................................................................................................................................................................................................................................................................................................
11.
Jantung
Inspeksi
..........................................................................................................................................................................................................................................................................................................................................
Palpasi
..........................................................................................................................................................................................................................................................................................................................................
Auskultasi
..........................................................................................................................................................................................................................................................................................................................................
Perkusi
..........................................................................................................................................................................................................................................................................................................................................
12.
Abdomen
Inspeksi
..........................................................................................................................................................................................................................................................................................................................................
Palpasi
..........................................................................................................................................................................................................................................................................................................................................
Auskultasi
..........................................................................................................................................................................................................................................................................................................................................
Perkusi
..........................................................................................................................................................................................................................................................................................................................................
13.
Sistem
Integumen
Inspeksi
..........................................................................................................................................................................................................................................................................................................................................
Kehangatan
..........................................................................................................................................................................................................................................................................................................................................
Warna
..........................................................................................................................................................................................................................................................................................................................................
Kelembaban
..........................................................................................................................................................................................................................................................................................................................................
Kelainan
pada Kulit
..........................................................................................................................................................................................................................................................................................................................................
14.
Eksremitas
Kesimetrisan
Otot
..........................................................................................................................................................................................................................................................................................................................................
Pemeriksaan
Oedem
..........................................................................................................................................................................................................................................................................................................................................
Kelainan-Kelainan
pada Ekstremitas dan Kuku
..........................................................................................................................................................................................................................................................................................................................................
15.
Genetalia
dan Sekitarnya
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
16.
Status
Neurologis
Tingkat
Kesadaran
..........................................................................................................................................................................................................................................................................................................................................
Tanda-tanda
perangsangan otot
..........................................................................................................................................................................................................................................................................................................................................
Fungsi
Motorik
..........................................................................................................................................................................................................................................................................................................................................
Fungsi
Sensorik
..........................................................................................................................................................................................................................................................................................................................................
Reflek
Fisiologis
..........................................................................................................................................................................................................................................................................................................................................
Reflek
Patologis
..........................................................................................................................................................................................................................................................................................................................................
XII.
PEMERIKSAAN TINGKAT PERKEMBANGAN
a.
Interaksi
sosial
................................................................................................................................................................................................................................................................................................................................................
b.
Bahasa
................................................................................................................................................................................................................................................................................................................................................
c.
Motor
Halus
................................................................................................................................................................................................................................................................................................................................................
d.
Motor
Kasar
................................................................................................................................................................................................................................................................................................................................................
Kesimpulan dari Pemeriksaan
Perkembangan
..............................................................................................................................................................................................................................................................................................................................................................
XIII.
INFORMASI LAIN
........................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................
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