FORMAT PENGKAJIAN KEPERAWATAN ANAK

1. IDENTITAS PASIEN
Nama :______________ No Reg :___________________
Usia :______________ Tanggal MRS :___________________
Nama orang tua :______________ Tanggal Pengkajian :___________________
Pekerjaan orang tua :______________
Alamat :______________
Suku :______________
Agama :______________
Pendidikan orang tua:______________
Diagnosa Medis :__________________________

2. KELUHAN UTAMA
a. Saat MRS :
______________________________________________________________________
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b. Saat Pengkajian :
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3. RIWAYAT KEHAMILAN DAN KELAHIRAN

a. Prenatal :___________________________________________________
b. Natal :___________________________________________________
c. Post Natal :___________________________________________________

4. RIWAYAT KESEHATAN MASA LALU

a. Penyakit masa lalu :______________________________________________
b. Riwayat dirawat di RS :______________________________________________
c. Riwayat pengobatan :______________________________________________
d. Riwayat tindakan Medis :______________________________________________
e. Riwayat alergi :______________________________________________
f. Riwayat kecelakaan :______________________________________________
g. Riwayat imunisasi :______________________________________________
h. Pola Asuh :______________________________________________
i. Riwayat tumbuh kembang yang lalu:
1) Motorik kasar :___________________________________________
 2) Motorik halus :______________________________________________
3) Sosialisasi :______________________________________________
4) Bahasa :______________________________________________

j. Genogram :
5. RIWAYAT KESEHATAN KELUARGA
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

6. PEMENUHAN KEBUTUHAN DASAR

Kebutuhan Dasar Sebelum MRS MRS

1. Pola Nutrisi

- Makanan

- Cairan

2. Pola Eliminasi

3. Pola Istirahat & Tidur

4. Personal hiegiene

5. Aktivitas

7. PEMERIKSAAN FISIK
a. Keadaan Umum :__________________________________________________
b. Tanda-tanda Vital :__________________________________________________
c. Pemeriksaan Kepala :__________________________________________________
d. Pemeriksaan Leher :__________________________________________________
e. Pemeriksaan Thorax :
1) Jantung :__________________________________________________
2) Paru :__________________________________________________
3) Mammae :__________________________________________________
4) Ketiak :__________________________________________________
f. Pemeriksaan Abdomen :__________________________________________________
g. Pemeriksaan Ekstremitas:_________________________________________________
h. Pemeriksaan Punggung dan Tulang Belakang:_________________________________
i. Pemeriksaan Genetalia :______________________________________
j. Pemeriksaan Integumen :______________________________________
k. Pemeriksaan Neurologi :______________________________________
8. PEMERIKSAAN PENUNJANG
a. Laboratorium :
 b. Radiologi :
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9. PEMERIKSAAN TINGKAT PERKEMBANGAN SAAT INI (DDST)

a. Motorik Kasar :
______________________________________________________________________
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b. Motorik Halus :
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
c. Sosialisasi :
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
d. Bahasa :
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

10. TERAPI
NO NAMA OBAT DOSIS KETERANGAN
11. KESIMPULAN
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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12. PERENCANAAN PULANG
a. Tujuan pulang :__________________________
b. Transportasi pulang :__________________________
c. Dukungan keluarga :__________________________
d. Antisipasi bantuan biaya setelah pulang :__________________________
e. Antisipasi masalah perawatan diri setelah pulang :__________________________
f. Pengobatan :__________________________
g. Rawat jalan ke :__________________________
h. Hal-hal yang perlu diperhatikan di rumah :__________________________
i. Keterangan lain :__________________________

Kepanjen, 2023
Perawat,

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