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ILMU KEPERAWATAN ANAK DALAM KONTEKS KELUARGA

FORMAT PENGKAJIAN

1. IDENTITAS PASIEN
Inisial Pasien :........................................
Usia :........................................
Jenis Kelamin :........................................
Diagnosa Medis :........................................
Tanggal Masuk RS :........................................
Tanggal Pengkajian :........................................
Nama Ayah / Ibu :........................................
Pekerjaan Ayah/Ibu :........................................
Pendidikan Ayah/Ibu :........................................
Alamat :........................................

2. KELUHAN UTAMA
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3. RIWAYAT KEHAMILAN
a. Pre natal
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b. Intra natal
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c. Post natal
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4. RIWAYAT KESEHATAN YANG LALU


a. Penyakit yang pernah diderita
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b. Riwayat dirawat di RS
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c. Riwayat Konsumsi obat-obatan
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d. Riwayat Operasi
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e. Riwayat Alergi
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f. Riwayat Imunisasi
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g. Lain-lain
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5. RIWAYAT KESEHATAN KELUARGA


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6. GENOGRAM (minimal 3 generasi)

7. RIWAYAT SOSIAL
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8. KEBUTUHAN DASAR
a. Makan :..........................................................................................................
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b. Minum :..........................................................................................................
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c. Tidur :..........................................................................................................
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d. Eliminasi :..........................................................................................................
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e. Aktivitas bermain :..........................................................................................................
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9. PEMERIKSAAN FISIK
a. Keadaan Umum :..........................................................................................................
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b. TB/BB :..........................................................................................................
c. Lingkar Kepala :..........................................................................................................
d. Tnda vital
- TD :..........................................................................................................
- HR :..........................................................................................................
- RR :..........................................................................................................
- Suhu :..........................................................................................................
e. Mata :..........................................................................................................
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f. Hidung :..........................................................................................................
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g. Mulut :..........................................................................................................
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h. Telinga :..........................................................................................................
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i. Dada :..........................................................................................................
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j. Jantung :..........................................................................................................
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k. Paru-paru :..........................................................................................................
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l. Abdomen :..........................................................................................................
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m. Punngung :..........................................................................................................
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n. Genitalia :..........................................................................................................
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o. Ekstremitas :..........................................................................................................
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p. Kulit :..........................................................................................................
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10. PEMERIKSAAN STATUS NUTRISI
a. Klinik :..................................................................................................................................
b. BB/U :..................................................................................................................................
c. TB/U :..................................................................................................................................
d. BB/TB :..................................................................................................................................
e. Simpulan:...............................................................................................................................
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11. PEMERIKSAAN PENUNJUANG


a. Laboratorium

Tgl Pemeriksaan Jenis Pemeriksaan Hasil Nilai Normal

b. Rontgen
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c. Terapi dan pemeriksaan lainnya
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12. PEMERIKSAAN TINGKAT PERKEMBANGAN SEBELUM DIRAWAT
a. Kemandirian dalam bergaul
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b. Motorik halus
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c. Motorik kasar
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d. Kognitif dan bahasa
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13. RUMUSAN MASALAH


a. Analisa Data

Analisa Data Masalah Keperawatan yang


Data
(Pohon Masalah) muncul (NANDA)
Data Analisa Data Masalah Keperawatan yang
(Pohon Masalah) muncul (NANDA)
Analisa Data Masalah Keperawatan yang
Data
(Pohon Masalah) muncul (NANDA)
Analisa Data Masalah Keperawatan yang
Data
(Pohon Masalah) muncul (NANDA)
b. Masalah Keperawatan
1) ...........................................................................................................................................
2) ...........................................................................................................................................
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7) ...........................................................................................................................................
8) ...........................................................................................................................................

14. DIAGNOSA KEPERAWATAN


a. .................................................................................................................................................
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b. .................................................................................................................................................
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c. .................................................................................................................................................
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d. .................................................................................................................................................
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f. .................................................................................................................................................
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g. .................................................................................................................................................
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h. .................................................................................................................................................
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15. RENCANA ASUHAN KEPERAWATAN (NURSING CARE PLANNING)

Diagnosa Keperawatan Rasional


No Tujuan Intervensi Keperawatan
(NANDA)
Diagnosa Keperawatan
No Tujuan Intervensi
(NANDA)
15. RENCANA ASUHAN KEPERAWATAN (NURSING CARE PLANNING)

Diagnosa Keperawatan
No Tujuan Intervensi Rasional
(NANDA)
Diagnosa Keperawatan
No Tujuan Intervensi Rasional
(NANDA)
No Diagnosa Keperawatan Tujuan Intervensi Rasional
(NANDA)
Diagnosa Keperawatan
No Tujuan Intervensi Rasional
(NANDA)
16. CATATAN PERKEMBANGAN

Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)


Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)
Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)
Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)
Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)
Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)
Hari Tanggal, jam Diagnosa Keperawatan Implementasi Evaluasi (SOAP)