FORMAT PENGKAJIAN( KEPERAWATAN ANAK )

A. PENGKAJIAN1. Biodata

a. Nama : ……………………………………………….b. Umur : ……………………………………………….c. Jenis Kelamin : ……………………………………………….d. Agama : ……………………………………………….e. Suku/ Bangsa : ……………………………………………….f. Alamat : ……………………………………………….g. Pekerjaan : ……………………………………………….h. Nomor Register : ……………………………………………….i. Tanggal MRS : ……………………………………………….j. Tanggal Pengkajian : ……………………………………………….k. Diagnosa Medis : ……………………………………………….

Biodata Penanggungjawaba. Nama : ……………………………………………….b. Umur : ……………………………………………….c. Jenis Kelamin : ……………………………………………….d. Agama : ……………………………………………….e. Pekerjaan : ……………………………………………….f. Pendidikan :

………………………………………………g. Status Perkawinan : ……………………………………………….h. Suku Bangsa : ……………………………………………….i. Alamat : ……………………………………………….

2. Keluhan Utama/ Alasan Masuk Rumah Sakita. Keluhan saat MRS

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

SEKOLAH TINGGI ILMU KESEHATAN (INSTITUTE OF HEALTH SCIENCES)

BANYUWANGI Jl. Letkol Istiqlah 109 Telp. (0333) 425270 Banyuwangi

Website : www.stikesbanyuwangi.ac.id

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b. Keluhan saat Pengkajian………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

3. Riwayat Penyakit Sekarang (PQRST)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………....

4. Riwayat Penyakit Masa Lalu…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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5. Riwayat Kesehatan keluarga……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

6. Riwayat Perkembangana. Motorik Halus ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………b. Motorik Kasar…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

c. Bahasa / Komunikasi…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

d. Adaptasi Sosial …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

7. Riwayat Psikososial dan Status Spiritual a. Riwayat Psikologis………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

b. Aspek Sosial………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

c. Aspek Spiritual/ Sistem Nilai Kepercayaan…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

8. Pola Kebiasaan Sehari – haria. Pola Nutrisi

1). Sebelum Sakit…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2). Saat Sakit…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

b. Pola Eliminasi1). Buang Air Besara). Sebelum Sakit………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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b). Saat Sakit…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2). Buang Air Kecila). Sebelum Sakit…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

b). Saat Sakit…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

c. Pola Kebersihan diri1). Sebelum Sakit…………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2). Saat Sakit……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

d. Pola Aktivitas, Latihan dan Bermain1). Sebelum Sakit……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………2). Saat Sakit……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

e. Pola Istirahat dan Tidur1). Sebelum Sakit………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2). Saat Sakit……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

9. Pemeriksaan FisikKeadaan Umuma. Keadaan Sakit

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

b. Tanda – tanda VitalTensi : Nadi : RR : Suhu :BB : TB : LL : LK :

c. Pemeriksaan Cepalo Caudal1). Kepala dan Rambut…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2). Hidung…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

3). Telinga…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

4). Mata…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

5). Mulut, Gigi, Lidah, Tonsil dan Pharing…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

6). Leher dan Tenggorokan…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

7). Dada/ Thoraka). Pemeriksaan Paru(1). Inspeksi…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

(2). Palpasi…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

(3). Perkusi…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

(4). Auskultasi…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

b). Pemeriksaan Jantung(1). Inspeksi…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

(2). Palpasi………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………

(3). Perkusi………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

(4). Auskultasi………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………8). Payudara(a). Inspeksi………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………

(b). Palpasi………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………….………………………………………………………………………………………………………………………………

9). Pemeriksaan Abdomen(a). Inspeksi………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… (b). Auskultasi………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………

(c). Palpasi………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………

(d). Perkusi………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

10). Ekstrimitas, Kuku dan Kekuatan Otot………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….…………………………………………………………………………11). Genetalia dan Anus………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………

12). Pemeriksaan Neurologi………………………….……………………………………………………………………………

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10. Pemeriksaan Penunjang………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….……………………………….………………………………………………………

11. Penatalaksanaan………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………

12. Harapan Klien/ Keluarga sehubungan dengan Penyakitnya…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….

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13. Genogram

Banyuwangi, ………, ………….. 20….Mahasiswa

ANALISA DATA

Nama Pasien :No. Register :

NO KELOMPOK DATA MASALAH ETILOGI

DIAGNOSA KEPERAWATAN

Nama Pasien :No. Register :

TANGGALMUNCUL DIAGNOSA KEPERAWATAN TANGGAL

TERATASITANDA

TANGAN

RENCANA ASUHAN KEPERAWATAN

Nama Pasien :No. Register :

TGL NO TUJUAN KRITERIA HASIL INTERVENSI RASIONAL T T

CATATAN KEPERAWATAN

Nama Pasien :No. Register :

TANGGAL JAM NODX TINDAKAN KEPERAWATAN T T

CATATAN PERKEMBANGAN

Nama Pasien :No. Register :

NODX TANGGAL TANGGAL TANGGAL