PROGRAM STUDI PROFESI NERS

STIKES SARI MULIA

FORMAT PENGKAJIAN BAYI, ANAK (POLI TUMBANG DAN POLI ANAK)
Nama Mahasiswa :
Tempat Praktek :
Tanggal Praktek :

I. PENGKAJIAN
A. IDENTITAS DATA
Nama : ............................. Alamat : ..............................
Tempat/Tgl.lahir : ............................. Agama : ..............................
Usia : ............................. Suku Bangsa : ..............................
Jenis Kelamin : ............................. Pendidikan Ayah : ..............................
Nama Ayah/Ibu : ............................. Pendidikan Ibu : ..............................
Pekerjaan Ayah/Ibu : .............................

B. KELUHAN UTAMA
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Riwayat kehamilan dan kelahiran

1. Prenatal: ..........................................................................................................

2. Intranatal: ........................................................................................................

3. Postanatal: ......................................................................................................

C. RIWAYAT PENYAKIT SEKARANG

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D. RIWAYAT PENYAKIT & KESEHATAN DAHULU/ MASA LALU
1. Penyakit waktu kecil : .......................................................................................
2. Pernah dirawat di RS : .....................................................................................
3. Obat-obatan yang digunakan : ........................................................................
4. Tindakan (operasi) : ........................................................................................
5. Alergi : .............................................................................................................
6. Kecelakaan: ....................................................................................................

E. RIWAYAT DAN KESEHATAN KELUARGA (Disertai genogram 3 Generasi,

Identitas (Nama, Umur) Status kesehatan.

F. RIWAYAT SOSIAL
1. Yang mengasuh: .............................................................................................
2. Hubungan dengan anggota keluarga: ..............................................................
3. Hubungan dengan teman sebaya: ...................................................................
4. Pembawaan secara umum: .............................................................................
5. Lingkungan rumah: ..........................................................................................

G. KEBUTUHAN DASAR (di RS dan di Rumah)

1. Makanan yang disukai/tidak disukai : .............................................................
Selera : .............................................................................
Alat makan yang dipakai : .............................................................................
Pola makan / jam : .............................................................................
2. Pola tidur : .............................................................................
Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa
saat tidur, dll) : .............................................................................
Tidur siang : .............................................................................
 3. Mandi : .............................................................................
4. Aktivitas bermain : .............................................................................
5. Eliminasi : .............................................................................

H. KEADAAN KESEHATAN SAAT INI

1. Diagnosa medis : .............................................................................
2. Status nutrisi : (hitung NCHS) ......................................................
3. Pemeriksaan DDST : .............................................................................

I. DATA TAMBAHAN
Pemeriksaan Penunjang :
Pemberian Imunisasi :
J. DATA FOKUS
1. Inspeksi ; ..........................................................................................................
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2. Palpasi ; ............................................................................................................
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3. Perkusi ; ...........................................................................................................
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4. Auskultasi ;......................................................................................................
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II. ANALISIS DATA
MASALAH
DATA KLIEN ETIOLOGI
KEPERAWATAN

III. PRIORITAS MASALAH

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 IV. RENCANA KEPERAWATAN
Tgl Pengkajian : Nama Pasien : An. Alamat rumah :
Nama Mhs : Umur : Nama ayah / ibu :
Ruang Praktek : Jenis Kelamin : Telepon yang dihubungi:
Nama Dokter : No. Rekam Medis : Diagnosa Medis :

Diagnosa Perencanaan
Keperawatan
Hari/
(Data Obyektif Tujuan keperawatan, Kriteria
Tanggal Intervensi keperawatan
dan Data Evaluasi
Subyektif)
 Nomer
Hari/ Implementasi Tanda
Diagnosa Jam Evaluasi keperawatan
Tgl keperawatan tangan
Keperawatan