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Lampiran 6. Format pengkajian anak
FORMAT PENGKAJIAN ANAK DI RUMAH SAKIT
Nama mahasiswa :
Dx:
Tempat praktek/ujian :
MRS:
Tanggal pengkajian :
BB:
I. IDENTITAS Nama (inisial)
:
TTL
:
Usia
:Pendidikan
:
Alamat
:
Agama
:
Nama ayah/ibu:
Pekerjaan ayah/ibu:
Pendidikan ayah/ibu :
Agama
:
Alarnat
:
Suku/Bangsa
:
II. KELUHAN UTAMA
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ KELUHAN TAMBAHAN_____________________________________________________________________________________________________________________________________________________
__________________________________________________________________________III. RIWAYAT PENYAKIT SEKARANG
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ IV. RIWAYAT MASA LAMPAU___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ V. RIWAYAT KELUARGA ( Disertai genogram )
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Keterangan:
---------
VI. RIWAYAT SOSIAL
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ VII. KEADAAN KESEHATAN SAAT INl
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ VIII. PENGKAJIAN POLA FUNGSIONAL (MENURUT GORDON)
1. Persepsi kesehatan dan pola manajemen kesehatan
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. Nutrisi- Pola Metabolik_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. Pola eliminasi
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 4. Aktivitas- Pola Latihan
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 5. Pola Istirahat -Tidur_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 6. Pola Kognitif -Persepsi
Anak:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Orang tua:
_______________________________________________________________________________________________________________________________________________7. Persepsi Diri - Pola Konsep Diri
Anak/bayi :
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Orang tua:
_______________________________________________________________________________________________________________________________________________8. Pola Peran-Hubungan
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Orang tua:
_______________________________________________________________________________________________________________________________________________9. Sexualitas
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Orang tua:
_______________________________________________________________________________________________________________________________________________
10. Koping -Pola Toleransi Stress_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
11. Nilai - Pola Keyakinan
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Orang tua:
_______________________________________________________________________________________________________________________________________________IX. PEMERIKSAAN FISIK
1. Keadaan umum: __________________________________________________________2. Tanda vital: _____________________________________________________________3. TB/BB ( persentil ): _______________________________________________________4. Lingkar Kepala: __________________________________________________________5. Mata: __________________________________________________________________6. Hidung: ________________________________________________________________7. Mulut: _________________________________________________________________8. Telinga: ________________________________________________________________9. Tengkuk: _______________________________________________________________10. Dada: __________________________________________________________________11. Jantung: ________________________________________________________________12. Paru-paru: ______________________________________________________________13. Perut: __________________________________________________________________14. Punggung: ______________________________________________________________15. Genitalia: _______________________________________________________________16. Ekstrimitas: _____________________________________________________________17. Kulit: __________________________________________________________________X. PEMERIKSAAN PERKEMBANGAN
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________XI. HASIL PEMERIKSAAN LAB DAN PENUNJANGNoParameterHasilSatuanNilai Normal
XII. INFORMASI LAIN
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________XIII. RINGKASAN RIWAYAT KEPERAWATAN
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________XIV. PATHWAYS KASUSXIII. ANALISA DATA
Data KlienMasalahPenyebab
XIV. PRIORITAS MASALAH
1.
2.
3.
XV. RENCANA KEPERAWATAN
NoHari/ TanggalDiagnosa
KeperawatanTujuanIntervensiRasional
XVI. IMPLEMENTASI KEPERAWATAN
NoHari/ tanggal/jamDiagnosa keperawatanTindakanRespon klienTanda tangan dan nama terang
XVII. EVALUASI KEPERAWATAN
NoHari/ Tgl/JamDiagnosa keperawatanEvaluasi (SOAP)
IX. CATATAN PERKEMBANGAN
Catatan perkembangan dilakukan sebelum melanjutkan pengelolaan kasus pada hari berikutnya. Fungsi catatan perkembangan adalah untuk mengetahui apakah masalah keperawatan klien masih ada atau tidak.
Hari/ Tgl/JamDiagnosa keperawatanPerkembangan (SOAP)
: klien
: garis perkawinan
: garis keturunan
: meninggal
: perempuan
: laki-laki
: serumah