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LAPORAN

PENGKAJIAN PENILAIAN

PERTUMBUHAN DAN  PERKEMBANG ANAK

       I.            PENGKAJIAN

Tanggal           :

Jam                  :

A .Data subyektif

Biodata Anak 

Nama anak                  :

Jenis kelamin               :

Tanggal lahir/ usia       :

Biodata orang tua

Nama ibu         :                                               Nama ayah                  : 

Umur               :                                               Umur                           :

Agama             :                                               Agama                         :

Pendidikan      :                                               Pendidikan                  :

Pekerjaan         :                                               Pekerjaan                     :

Alamat             :                                               Alamat                        :

1.    Keluhan utama

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………........

2.    Alasan datang

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………........

3.    Riwayat perkawinan :

·      Lama menikah                           :

·      Usia pertama menikah               :

·      Perkawinan ke berapa                :

·      Jumlah anggota keluarga           :

·      Urutan anak ke              :

·      Yang mengasuh anak     :

4.    Riwayat kesehatan yang lalu

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

5.    Riwayat kesehatan sekarang

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

6.    Riwayat kesehatan keluarga

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

7.    Riwayat prenatal

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………….

8.    Riwayat intranatal

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

9.    Riwayat postnatal

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

10.              Pola aktivitas shari- hari

            Pola nutrisi                  :

            Pola eliminasi              :

            Pola aktivitas               :

                        Pola istirahat               :

            Pola kebersihan           :

11.              Data imunisasi

Jenis                                                     :

 waktu pemberian                                :

 reaksi setelah pemberian                     :

tindakan untuk mengatasi reaksi         :

12.              Riwayat pemberian makanan tambahan

Usia pemberian            :

Jenis MP ASI              :

Frekwensi                    :

Jumlah pemberian        :

13.              Riwayat perkembangan sesuai dengan usia

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

14.              Genogram keluarga

15.              Riwayat social budaya

Social

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………                                    

Latar budaya

            ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………           

B . data obyektif

Keadaan umum           :

Kesadaran                   :

Td                                :

Nadi                            :

Suhu                            :

Rr                                :

Tb                                :

Bb                                :

Lingkar kepala             :

Lingkar dada               :

Lingkar Lengan          

PEMERIKSAAN FISIK

Inspeksi ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Palpasi

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

AUSKULTASI

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

PERKUSI

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

    II.            DIAGNOSA MASALAH

………………………………………………………………………………………………………………………………………………………………………………………………

 III.            IDENTIFIKASI KEBUTUHAN SEGERA

………………………………………………………………………………………………………………………………………………………………………………………………

 IV.            MASALAH POTENSIAL

………………………………………………………………………………………………………………………………………………………………………………………………

    V.            INTERVENSI (sesuaikan  dengan masalah)

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

 VI.            IMPLEMENTASI

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

VII.            EVALUASI

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………