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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
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
b. Keluhan saat Pengkajian………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3. Riwayat Penyakit Sekarang (PQRST)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………....
4. Riwayat Penyakit Masa Lalu…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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………………………….……………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………..…
10. Pemeriksaan Penunjang………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….……………………………….………………………………………………………
11. Penatalaksanaan………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………
12. Harapan Klien/ Keluarga sehubungan dengan Penyakitnya…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………….
……………………………….………………………………………………………………
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