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FORMAT PENGKAJIAN ANAK
Nama Mahasiswa : ………………………………
Tempat Praktek : ………………………………
Tanggal Praktek : ………………………………
Pengkajian Dilakukan Tanggal................jam................WIB
I. IDENTITAS
Inisial Nama : …………………... Alamat : …………
Tempat/tgl.lahir : …………………... Agama : …………
Usia : …………………... Suku Bangsa : …………
Nama Ayah/Ibu : …………………... Pendidikan ayah : …………
Pekerjaan Ayah : …………………... Pendidikan ibu : …………
Pekerjaan Ibu : …………………...
II. RIWAYAT KEPERAWATAN
a. Keluhan Utama (saat masuk RS)
................................................................................................................................................
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b. Keluhan utama (saat pengkajian)
................................................................................................................................................
..........................................................................................
c. Riwayat Perjalanan Penyakit
................................................................................................................................................
......................................................................................
d. Riwayat Kehamilan dan Kelahiran Anak
Prenatal :
……………………………………………………………........................................
Internatal :
……………………………………………………………........................................
Postnatal :
……………………………………………………………..........................................
d. Riwayat Masa Lampau
1.Penyakit waktu kecil : ……………………………………..................,,,,,,,,,,,,,,,,,,,
2.Pernah dirawat di RS :
…………………………………….......................................
3.Obat-obatan yang digunakan :
…………………………………….......................................
4.Tindakan (operasi) : ……………………………………………..........................
5.Alergi :……………………………………………..........................
6.Kecelakaan : ……………………………………………..........................
7.Imunisasi : …………………………………………….........................
e. Riwayat Keluarga
Genogram
f. Riwayat Sosial
Yang mengasuh : …………………………………….....................
Hubungan dengan anggota keluarga : ……………………………….............................
Hubungan dengan teman sebaya : …………………………………..........................
Pembawaan secara umum : …………………………………….....................
Lingkungan rumah : …………………………………….....................
IV. KEADAAN KESEHATAN SAAT INI
................................................................................................................................................
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V. PENGKAJIAN FISIK
DOMAIN (SAFETY/PROTECTION)
Composmentis ( ), Apatis ( ), Somnolen ( ), Sopor ( ),Soporocoma ( ) Coma ( )
TTV : Suhu........., Nadi........x/min, TD...............mmHg, RR..........x/min
Masalah Keperawatan:
1..........................................................................................................................................................
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM SENSORI PERSEPSI (DOMAIN 5 PERCEPTION/COGNITION)
a. Kesan Umum
Tampak Sakit: ringan ( ), sedang ( ), berat ( ), pucat ( ), sesak ( ), kejang ( )
b. Kepala
Bentuk:........................ Hematoma( ), Luka( )
Fontanel: cekung ( ), Datar ( ), Keras ( ), Lunak ( )
Rambut: warna...............mudah dicabut ( ), ketombe( ), kutu( )
c. Mata
Mata: jernih( ), mengalir, kemerahan( ), sekret( )
Visus: 6/6( ), 6/300( ), 6/ tak terhingga( ),
Pupil: Isokor( ), anisokor( ), miosis( ), midriasis( ),
reaksi terhadap cahaya: kanan Positif( ), negatif( ), kiri negatif( ) positif( ),
alat bantu: kacamata( ), Softlens( )
Conjungtiva: merah jambu( ), anemis( )
Sklera: Putih( ), Ikterik( )
d. Telinga
Simetri( ), sekret( ), radang( ), Pendengaran: ( ), kurang( ), tuli( )
e. Hidung : Simetris( ), pilek( ), epistaksis( )
f. Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
Masalah Keperawatan:
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM RESPIRASI (DOMAIN 3 ELIMINATION/EXCHANGE, CLASS 4)
g. Jalan nafas: Sputum ( ), warna sputum ( )
konsisitensi:........................................
Batuk ( ) frekuensi:..............................
h. Dada
Bentuk: Simetris ( ), Barrel chest/dada tong( ), pigeon chest/dada burung ( ) benjolan
( ), dll………………..
Paru-paru:
Inspeksi: RR………x/ min,
Palpasi: Normal ( ), ekspansi pernafasan( ), taktil fremitus( )
Perkusi: Normal/ Sonor( ), redup/pekak( ), hiper sonor( )
Auskultasi: irama( ), teratur( ),
Suara nafas: vesicular( ), bronkial( ), Amforik ( ), Cog Wheel Breath Sound ( )
metamorphosing breath sound ( )
Suara Tambahan: Ronki ( ), pleural friction( )
Masalah Keperawatan:
1..........................................................................................................................................................
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM KARDIOVASKULER (DOMAIN ACTIVITY/REST, CLASS 4)
Jantung
Inspeksi: ictus cordis/denyut apeks( ), normal( ) melebar( )
Palpasi: kardiomegali( )
Perkusi: redup( ), pekak( )
Auskultasi: HR...............x/mnt. Aritmia( ),Disritmia( ) , Murmur ( )
Masalah Keperawatan:
1..........................................................................................................................................................
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM PENCERNAAN (DOMAIN 2 NUTRITION)
i. Mulut
Trismus ( ), Halitosis ( )
Bibir: lembab( ), pucat( ), sianosis( ), labio/palatoskizis( ), stomatitis( )
Gusi: ( ), plak putih( ), lesi( )
Gigi: Normal( ), Ompong( ), Caries( ), Jumlah gigi:...................
Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
j. Leher
Kaku Kuduk ( ) Simetris( ), Benjolan ( ) Tonsil ( )
Kelenjar Tiroid : normal ( ), pembesaran ( )
Tenggorok : kesulitan menelan ( ),
dll..................................................................................................
Kebutuhan Nutrisi dan Cairan
BB sebelum sakit: kg BB sakit: kg
Makanan yang disukai:..........................
Selera makan:...........................
Alat makan yang digunakan:........................
Pola makan( x/ hari):......................
Porsi makan yang dihabiskan:............................
Pola Minum .............................gelas/hari) jenis air minum:.....................................................
k. Abdomen
Inspeksi : Bentuk: simetris( ), tidak simetris( ), kembung( ), asites( ),
Palpasi : massa ( ), nyeri ( )
Kuadran I :
Kuadran II :
Kuadran III :
Kuadran IV :
Auskultasi : bising usus........................x/mnt
Perkusi : Timpani ( ), redup ( )
BAB : warna........................................Frekuensi................................x/hari
Konsisitensi:.................................... lendir ( ), darah ( ), ampas ( )
Konstipasi ( )
Masalah Keperawatan:
1..........................................................................................................................................................
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM REPRODUKSI (DOMAIN 8 SEXUALITY)
l. Genitalia dan Anus
Laki-laki
Penis: normal/ada ( ), Abnormal…………………,
Scrotum dan testis: normal( ), hernia( ), hidrokel( )
Anus ; normal/ada ( ), atresia ani( )
Perempuan
Vagina: sekret( ), warna( )
Anus: normal/ada ( ), atresia ani( )
Masalah Keperawatan:
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM PERKEMIHAN (DOMAIN 3 ELIMINATION/EXCHANGE, CLASS 1)
Pola Eliminasi
BAK:
Warna:
Konsistensi:
Frekuensi: x/ hari
Urine Output : cc
Penggunaan Kateter:.............................................................................................
Vesika Urinaria: Membesar .....................Nyeri tekan............................
Gangguan; Anuaria ( ), Oliguria ( ), Retensi Urin ( ), nokturia ( ), Inkontinensia Urin
( ), Poliuria ( ), Dysuria ( )
Jelaskan:...............................................................................................................
Masalah Keperawatan:
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM MUSKULO SKELETAL (DOMAIN 13 GROWTH/DEVELOPMENTAL,
D.COMFORT,)
m. Ekstremitas
Amelia ( ), Sindaktili ( ), Polidaktili( )
Reflek Pat0logis :
Babinsky ...............................................................................................
Kernig ...................................................................................................
Brudzinsky.............................................................................................
Reflek Fisiologis:
Biceps.................................................................................................................
Triceps...............................................................................................................
Patella.................................................................................................................
Ekstremitas:
Superior (Atas) Inferior (Bawah)
Warna
Edema
Luka
Tremor
Clubbing
Placids
Parese
Kekuatan Otot
(1-5)
Persendian:
Nyeri Sendi ( ), pergerakan sendi:.......................
ROM ( Range Of Motion):
Kekuatan Otot :
Kelainan Otot:
Masalah Keperawatan:
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM NEUROBEHAVIOUR (DOMAIN COPING/STRESS TOLERANCE, D.
GROWTH)
GCS :.......
E:........................................................................................
V: .......................................................................................
M:.......................................................................................
PEMERIKSAAN TINGKAT PERKEMBANGAN (DDST)
Kemandirian dan bergaul : ……………………………………..................
…………………………………….......,..........
Motorik Halus : ……………………………….........................
………………………………............
,...............
Kognitif dan bahasa : …………………………………......................
……………………………………....................
Motorik kasar : ……………………………………...................
……………………………………....................
Masalah Keperawatan:
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SISTEM INTGUMEN (DOMAIN 3 ELIMINATION/EXCHANGE)
Kulit
Warna kulit :
Sianosis ( ), I kterus ( ), eritematosus rash ( ), discoid lupus ( ), oedema ( ),
Bula ( ), Ganggren ( ), nekrotik jaringan ( ), Hiperpigmentasi ( )
Echimosis ( ), Petekie ( )
Turgor Kulit: elastis ( ), tidak elastis ( )
Masalah Keperawatan:
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3..........................................................................................................................................................
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PERSONAL HYGIENE: (DOMAIN ACTIVITY /REST)
Mandi:...................x/mnt
Sikat gigi :........................................x/mnt
Ganti Pakaian :..................................x/mnt
Memotong kuku:...............................x/mnt
Masalah Keperawatan:
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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KEBUTUHAN ISTIRAHAT DAN POLA TIDUR(DOMAIN ACTIVITY /REST)
Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa saat tidur, dll):
Kebiasaan Tidur siang:......................................jam/hari
Masalah Keperawatan:
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DOMAIN PERSEPSI DIRI
Perasaaan klien terhadap penyakit yang
didieritanya.................................................................................
Persepsi klien terhadap
dirinya..............................................................................................................................
Konsep
diri.......................................................................................................................................................
................
Tingkat
kecemasan...........................................................................................................................................
............
Citra Diri/Bodi
image:.................................................................................................................................................
Masalah Keperawatan:
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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PEMERIKSAAN PENUNJANG:
TERAPI :
Lampiran 6
FORMAT PENGKAJIAN NEONATUS (NICU)
Nama Mahasiswa : ………………………………
Tempat Praktek : ………………………………
Tanggal Praktek : ………………………………
Pengkajian Dilakukan Tanggal................jam................WIB
I. IDENTITAS
Inisial Nama : …………………... Alamat : …………
Tempat/tgl.lahir : …………………... Agama : …………
Usia : …………………... Suku Bangsa : …………
Nama Ayah/Ibu : …………………... Pendidikan ayah : …………
Pekerjaan Ayah : …………………... Pendidikan ibu : …………
Pekerjaan Ibu : …………………...
Berat bayi :
Panjang Badan :
Apgar ScorE :
Usia Gestasi :Berat Badan : Panjang Badan :
Indikasi persalinan :
Tidak ada ( ) Ada ( )
Aspirasi mekonium :
Denyut jantung janin abnormal ( )
Prolaps tali pusat/lilitan tali pusat ( )
Ketuban pecah dini ( ); beberapa jam : Berat Ibu
Usia Gravida Partus Abortus
Persalinan:
Pervaginam ( )
Sectio caesarea ( ); Alasan :
Komplikasi kehamilan:
Tidak ada ( ) Ada ( )
Perawatan antenatal ( )
Ruptur plasenta / plasenta previa ( )
Pre eklampsia / toxcemia ( )
Suspect sepsis ( )
Persalinan premature/post matur ( )
Masalah lain :
A. Pemeriksaan Fisik
Intruksi: Beri tanda cek () pada istilah yang tepat/ sesuai dengan data-data di bawah ini. Gambarkan semua temuan abnormal secara objektif, gunakan kolom data tambahan bila perlu.
SISTEM PERSEPSI SENSORI (DOMAIN 5 PERCEPTION/COGNITION)
1. Kepalaa. Fontanel anterior Lunak ( ) Tegas ( )Datar ( ) Menonjol ( )
Cekung ( )b. Sutura sagitalis:Tepat ( ) Terpisah ( ) Menjauh ( )Tumpang tindih ( )c. Gambaran wajah Simetris ( ) Asimetris ( )d. Molding ( ) Caput succedaneum ( ) Cephalhematoma ( )
2. Mata Bersih ( ) Sekresi ( )Jarak interkantus Sklera: Putih ( ) ikterik ( )
5. Bibira. Bibir : normal ( ) sumbing ( )b. Sumbing langit-langit/palatum ( )
1. Telinga, Hidung, Tenggoroka. Telinga: Normal ( )Abnormal ( ) Sekret( )b. Hidung: Simetris ( )Asimetris ( ) Sekret ( ) Nafas cuping hidung ( )c. Tenggorok: Tonsil( ), radang( )
Masalah Keperawatan:
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2..........................................................................................................................................................
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SISTEM RESPIRASI
7. ToraksSimetris ( ) Retraksi dada ( ) Klavikula normal ( )
Paru-parua. Suara nafas kanan kiri sama ( ) Tidak sama ( )b. Suara nafas bersih ( ) ronchi ( ) sekresi ( )
wheezing ( ) vesikuler ( ) tidak spontan ( )c. Respirasi spontan ( ) Tidak spontan ( )
Alat bantu nafas:
( ) Nasal kanul ( ) O2 / incubatorKonsentrasi O2 : ltr/menit
Masalah Keperawatan:
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2..........................................................................................................................................................
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SISTEM KARDIOVASKULER (DOMAIN ACTIVITY/REST)Jantung
Inspeksi: ictus cordis/denyut apeks( ), normal( ) melebar( )
Palpasi: kardiomegali( )
Perkusi: redup( ), pekak( )
Auskultasi: HR...............x/mnt. Aritmia( ),Disritmia( ) , Murmur ( )
Masalah Keperawatan:
1..........................................................................................................................................................
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM PENCERNAAN (DOMAIN 2 NUTRITION)
Mulut
Trismus ( ), Halitosis ( )
Bibir: lembab( ), pucat( ), sianosis( ), labio/palatoskizis( ), stomatitis( )
Gusi: ( ), plak putih( ), lesi( )
Gigi: Normal( ), Ompong( ), Caries( ), Jumlah gigi:...................
Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
Kebutuhan Nutrisi dan Cairan
BB sebelum sakit: kg BB sakit: kg
Makanan yang disukai:..........................
Selera makan:...........................
Alat makan yang digunakan:........................
Pola makan( x/ hari):......................
Porsi makan yang dihabiskan:............................
Pola Minum .............................gelas/hari) jenis air minum:.....................................................
Abdomen
Inspeksi : Bentuk: simetris( ), tidak simetris( ), kembung( ), asites( ),
Palpasi : massa ( ), nyeri ( )
Kuadran I :
Kuadran II :
Kuadran III :
Kuadran IV :
Auskultasi : bising usus........................x/mnt
Perkusi : Timpani ( ), redup ( )
BAB : warna........................................Frekuensi................................x/hari
Konsisitensi:.................................... lendir ( ), darah ( ), ampas ( )
Konstipasi ( )
Masalah Keperawatan:
1..........................................................................................................................................................
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM REPRODUKSI (DOMAIN 8 SEXUALITY)
Genitalia dan Anus
Laki-laki
Penis: normal/ada ( ), Abnormal…………………,
Scrotum dan testis: normal( ), hernia( ), hidrokel( )
Anus ; normal/ada ( ), atresia ani( )
Perempuan
Vagina: sekret( ), warna( )
Anus: normal/ada ( ), atresia ani( )
Masalah Keperawatan:
1..........................................................................................................................................................
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM MUSKULO SKELETAL (DOMAIN 13 GROWTH/DEVELOPMENTAL,
D.COMFORT,)
ReflekMoro :Mengisap :Rooting :
Dan lain-lain:........................................................................................................................................................
ROM:
Tonus/aktifitasa. Aktif ( ) Tenang ( ) Letargi ( ) Kejang ( )b. Menagis keras ( ) lemah ( ) melengking ( )
Sulit menangis ( )
Ekstremitas
Amelia ( ), Sindaktili ( ), Polidaktili( )
Reflek Pat0logis :
Babinsky ...............................................................................................
Kernig ...................................................................................................
Brudzinsky.............................................................................................
Reflek Fisiologis:
Biceps.................................................................................................................
Triceps...............................................................................................................
Patella.................................................................................................................
Masalah Keperawatan:
1..........................................................................................................................................................
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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SISTEM INTEGUMEN (DOMAIN ELIMINATION/EXCHANGE)Kulit
a. Warna Pink ( ) pucat ( ) Jaundice ( )Sianosis pada kuku ( ) sirkumoral ( )Periorbital ( ) seluruh tubuh ( )
b. Kemerahan (rash) ( )c. Tanda lahir: ( ); sebutkan: d. Turgor kulit: elastis ( ) tidak elastis ( ) edema ( ) Lanugo ( )
Suhua. Lingkungan
Penghangat radian ( ) Pengaturan suhu ( )Inkubator ( ) Suhu ruang ( ) Boks terbuka ( )
Masalah Keperawatan:
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2..........................................................................................................................................................
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3..........................................................................................................................................................
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DOMAIN 7 ROLE RELATIONSHIP
Struktur keluarga (genogram tiga generasi) :
Budaya: Suku : Agama: Bahasa Utama : Perencanaan makanan bayi : Masalah sosial yang penting: Hubungan orang tua dan bayi:
- Orang terdekat yang dapat dihubungi: - Orang tua berespon terhadap penyakit: ya ( ) tidak ( )
Respon: - Orang tua berespon terhadap hospitalisasi: ya ( ) tidak ( )
Respon:
- Riwayat anak lain:
Jenis kelamin anak
Riwayat persalinan Riwayat imunisasi
TERAPI
PEMERIKSAAN PENUNJANG
