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ASUHAN KEPERAWATAN NEONATAL

......................................................................................................................................................

PENGKAJIAN Tanggal MRS/Jam

:

Tanggal Pengkajian/Jam

:

Tempat

:

A. DATA SUBYEKTIF 1. Identitas Nama Bayi

:...............................................................................................................................

Tanggal/Jam Lahir

:...............................................................................................................................

Jenis Kelamin

:................................................................................................................................

Umur

:...............................................................................................................................

Dx Medis

:................................................................................................................................

2. Keluhan Utama a) Saat MRS

:…………….............................................................................................................. ................................................................................................................................. .................................................................................................................................

b) Saat Pengkajian

:……………….......................................................................................................... ................................................................................................................................ ................................................................................................................................. ................................................................................................................................. .................................................................................................................................

3. Identitas Orang Tua Ayah

Ibu

Nama

:

:

Umur

:

:

Suku/Bangsa

:

:

Agama

:

:

Pendidikan

:

:

Pekerjaan

:

:

Alamat

:

:

4. Riwayat Prenatal

-

Kehamilan ke

:....................................................................................................................

-

Tempat ANC

:....................................................................................................................

-

Imunisasi TT

:.....................................................................................................................

-

Obat-Obatan yang pernah diminum selama hamil :.....................................................................................

-

Penerimaan Ibu/Keluarga Terhadap kehamilan

:...................................................................................

-

Masalah yang pernah dialami ibu saat hamil

:.....................................................................................

4. Riwayat

IntraNatal

-

Persalinan ke

:..........................................................................................................

-

Tempat dan penolong persalinan

:..........................................................................................................

-

Masalah saat persalinan

:...........................................................................................................

-

Jenis Persalinan

:............................................................................................................

-

Lama persalinan

:.............................................................................................................

-

Keadaan bayi saat lahir

:.............................................................................................................

-

Segera menangis/tidak

:..............................................................................................................

5. Riwayat

Natal

-

Keadaan bayi baru lahir

-

Lahir tanggal

: .....................................,jam..........................................................

-

Masa gestasi

: ........................................ minggu

-

BB/PB lahir

-

Nilai APGAR : 1 menit/5menit/10 menit/2 jam:

:.........................gram, ......................cm

No

Kriteria

1

Denyut Jantung

2

Usaha nafas

3

Tonus otot

4

Reflek

5

Warna kulit

1 menit

5 menit

10 menit

2 jam

TOTAL

6.

Pola Fungsi kesehatan Kebutuhan Dasar

Saat MRS

Saat Pengkajian

1. Cairan & Makanan 2. Eliminasi 3. Istirahat & Tidur 4. Personal hygiene 5. Aktivitas

7.

Status Imunisasi

B. DATA OBJEKTIF 1. Pemeriksaan Umum

:.......................................................................................................................................

a. Keadaan umum

: ......................................................................................................................................

b. kesadaran

: ......................................................................................................................................

c. Tanda vital Nadi

:.......................................................................................................................................

Pernafasan

:.....................................................................................................................................

Suhu

:.......................................................................................................................................

2. Pemeriksaan Antropometri BB

:....................................................................................................................................................

PB

:....................................................................................................................................................:

LK

:....................................................................................................................................................

LD

.....................................................................................................................................................:

LLA

:....................................................................................................................................................

2. Pemeriksaan Fisik Kepala

: ...................................................................................................................................................

Muka

:....................................................................................................................................................

Ubun-ubun

: ....................................................................................................................................................

Mata

: ....................................................................................................................................................

Hidung

: ....................................................................................................................................................

Telinga

: ....................................................................................................................................................

Mulut

: ....................................................................................................................................................

Leher

: ....................................................................................................................................................

Dada

: ....................................................................................................................................................

Tali pusat

: ....................................................................................................................................................

Abdomen

: ....................................................................................................................................................

Punggung

: ....................................................................................................................................................

Ekstermitas

: ....................................................................................................................................................

Genitalia

: ....................................................................................................................................................

Anus

: ....................................................................................................................................................

3. Pemeriksaan Neurologis Moro

: ....................................................................................................................................................

Rooting

: ....................................................................................................................................................

Sucking

: ....................................................................................................................................................

Swallowing

: ....................................................................................................................................................

Walking

: ....................................................................................................................................................

Graphs

: ....................................................................................................................................................

Tonicneck

: ....................................................................................................................................................

Burning

: ....................................................................................................................................................

5. Pemeriksaan Penunjang a. Pemeriksaan Laboratorium ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... b. Terapi ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... ..................................................................................................................................................................... .....................................................................................................................................................................