Format Pengkajian Bayi Ok.doc

FORMAT DOKUMENTASI ASUHAN KEPERAWATAN PADA BAYI _____________________________________________________________________

Disusun Oleh : NAMA : ……………......................... NIM : ………………………………..

KEMENTERIAN KESEHATAN RI POLITEKNIK KESEHATAN KEMENKES MALANG JURUSAN KEPERAWATAN PROGRAM STUDI D-IV KEPERAWATAN MALANG TAHUN 2017 FORMAT PENGKAJIAN

A. PENGKAJIAN A1. PENGUMPULAN DATA

I.

BIODATA IDENTITAS BAYI Nama No. Register Umur Jenis kelamin Alamat Suku bangsa Tanggal lahir/Umur Tgl MRS Tanggal pengkajian Diagnosa medis Urutan anak

II.

IDENTITAS BAPAK :..................................... :..................................... :..................................... :..................................... :..................................... :..................................... :..................................... :..................................... :..................................... :..................................... : ....................................

Nama Umur Jenis kelamin Alamat Pendidikan Pekerjaan Suku bangsa No. Tlp/HP

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

IDENTITAS IBU

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

Nama Umur Jenis kelamin Alamat Pendidikan Pekerjaan Suku bangsa No. Tlp/HP

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

KELUHAN UTAMA/ALASAN KUNJUNGAN .......................................................................................................................................................... .......................................................................................................................................................... ..........................................................................................................................................................

III.

RIWAYAT KESEHATAN A. RIWAYAT KEHAMILAN 1) Jumlah kunjungan ke bidan/dokter : .................................................................................... 2) Pendidikan kesehatan yang didapatkan : ............................................................................ 3) Kenaikan BB selama hamil : ................................................................................................ 4) Penyakit yang diderita ibu saat hamil : ................................................................................. 5) Pemeriksaan Lab/Radiologi saat hamil: ............................................................................... 6) Keluhan saat hamil: ............................................................................................................. 7) Imunisasi selama hamil: ....................................................................................................... 8) Obat-obatan/vitamin yang dikonsumsi: ................................................................................. 9) Riwayat minum jamu: ........................................................................................................... 10)Riwayat dipijat (Bhs Jawa: dioyok): ......................................................................................

B. RIWAYAT KELAHIRAN 1) Lama persalinan: .................................................................................................................. 2) Komplikasi persalinan: ......................................................................................................... 3) Cara persalinan: ........................................................................................ 4) Tempat melahirkan: ............................................................................................................. 5) Penolong persalinan: ........................................................................................................... 6) Usia gestasi: ........................................................................................................................ 7) Kondisi air ketuban: ..............................................................................................................

C. RIWAYAT POST NATAL 1) Pernafasan/usaha bernafas (denga/tanpa bantuan): ........................................................ 2) Tonus otot: ........................................................................................................................ 3) Skor APGAR: .................................................................................................................... 4) Kebutuhan resusitasi (Jenis dan lamanya): ...................................................................... 5) Obat yang diberikan: ........................................................................................................ 6) Trauma lahir: ................................................................................................................... IV.

PEMERIKSAAN FISIK (HEAD TO TOE) A. Keadaan Umum Postur: ......................................................................................................................... Tangisan: APVU: B. Kepala dan rambut Kebersihan : ............................................................................................................... Bentuk kepala : .......................................................................................................... Keadaan rambut :........................................................................................................ Keadaan kulit kepala : caput succedanum, cefalohematom: .................................... Fontanela anterior : lunak/menonjol/tegas/cekung/datar: ........................................ Sutura sagitalis : tepat/terpisah/menjauh: ................................................................. Distribusi rambut : merata/tidak merata: .................................................................... C. Mata Kebersihan : .................................................................................................................. Sclera : .......................................................................................................................... Conjungtiva : ................................................................................................................. Pupil : ............................................................................................................................. Gerakan bola mata : ..................................................................................................... Pupil: ............................................................................................................................... Sekret: ............................................................................................................................ Jarak inner canthus: (normal, lebar) ................................................................................. D. Hidung Pernafasan Cuping hidung : .......................................................................................... Struktur :......................................................................................................................... Kelainan lain : polip/perdarahan/peradangan: ............................................................... Sekresi: ........................................................................................................................ E. Telinga Kebersihan : ....................................................................................................................... Sekresi : ............................................................................................................................. Struktur : ............................................................................................................................. Fistulaaurikel: .................................................................................................................... F. Mulut dan Tengorokan Jamur (stomatitis, moniliasis): ........................................................................................... Kelaianan bibir dan rongga mulut (gnato/labio/palato skizis): ............................................ Problem menelan : ............................................................................................................. Warna bibir: ............................................................................................................. G. Leher

Venajugularis : ................................................................................................................... Arteri karotis : ..................................................................................................................... Pembesaran tiroid/limfe : ................................................................................................... Torticoliis: .......................................................................................................................... H. Dada/Thorak (jantung dan Paru) Bentuk dada: ...................................................................................................................... Pergerakan dinding dada: ........................................................................................ Tarikan dinding dada ke atas/bawah: .................................................................................. Suara pernafasan: ............................................................................................................... Frekwensi nafas: ................................................................................................................. Abnormalitas suara nafas: ................................................................................................. Suara jantung: .................................................................................................................... I.

Ekstremitas atas Tonus otot: .......................................................................................................................... Trauma, deformitas: .......................................................................................................... Kelainan struktur: ................................................................................................................ CRT: .............................................................................................................

J. Perut Bentuk perut: ...................................................................................................................... Bising usus: ......................................................................................................................... Ascites: ............................................................................................................. Massa: ............................................................................................................... Turgor kulit: ....................................................................................................................... Vena: .............................................................................................................................. Hepar: ............................................................................................................. Lien: ....................................................................................................................... Tali pusat: kebersihan, warna kulit sekitar ..................................................................... Distensi: ............................................................................................................................ K. Punggung Spina bifida: ........................................................................................................................ Deformitas: ........................................................................................................................ Kelainan struktur: ................................................................................................................ L. Genetalia dan anus Keadaan kelamin luar : ...................................................................................................... Anus : ............................................................................................................................... Kelainan: ........................................................................................................................ M. Ekstremitas bawah Tonus otot: ......................................................................................................................... Trauma, deformitas: ......................................................................................................... Kelainan struktur: .............................................................................................................. N. Integumen Warna kulit: ................................................................................................................... Kelembaban: ..................................................................................................................... Lesi: ...................................................................................................................... Warna kuku, rambut: ....................................................................................................... Kelainan: ..........................................................................................................................

V.

PENGUKURAN ANTROPOMETRI Berat badan: .......................................................................................................................... Panjang badan: ....................................................................................................................... Lingkar kepala: ...................................................................................................................... Lingkar dada: .......................................................................................................................... Lingkar lengan Atas: ............................................................................................................

VI.

REFLEKS PRIMITIF Berkedip: ............................................................................................................................ Rooting

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

Menghisap :............................................................................................................................ Menggenggam :........................................................................................................................ Neck righting: ...........................................................................................................................Moro

:

............................................................................................................................. VII.

RIWAYAT IMUNISASI Sebutkan imunisasi yang sudah diberikan beserta umur saat diimunisasi ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ...................................................................................................................................................

VIII.

PEMENUHAN KEBUTUHAN DASAR A. OKSIGEN Kebutuhan oksigen: .......................................................................................................... Dosis oksigen: ................................................................................................................... Cara pemberian: .......................................................................................................... B. CAIRAN: Kebutuhan cairan dalam 24 jam: ..................................................................................... Jenis cairan yang diberikan: ........................................................................................... Cara/rute pemberian: ....................................................................................................... Balance cairan dalam 24 jam: Intake: .............................................................................................................................. Output : ............................................................................................................................ IWL: .............................................................................................................................. Kesimpulan: .................................................................................................................. C. Nutrisi Kebutuhan kalori: ............................................................................................................ Bentuk/jenis nutrisi yang diberikan: .................................................................................... Cara pemberian: ............................................................................................................. Frekwensi pemberian: .................................................................................................. D. ELIMINASI URINE Volume urine:.................................................................................................................. Warna:............................................................................................................................ Frekwensi:......................................................................................................................... Cara BAK (spontan/kateter):............................................................................................

E. ELIMINASI ALVI Pengeluaran Mekoneum: ................................................................................................ Volume feses:................................................................................................................... Warna feses:.................................................................................................................... Konsistensi: ...................................................................................................................... Frekwensi:......................................................................................................................... Darah, lendir dalam feses:................................................................................................ F.

TIDUR Jumlah jam tidur dalam 24 jam: ..................................................................................... Kualitas tidur (sering terbangun, rewel, tidak bisa tidur): ...............................................

G. PSIKOSOSIAL Yang mengasuh: ...........................................................................................................

IX.

DATA PENUNJANG

A. Radiologi Tanggal

Jenis Pemeriksaan

Hasil Pemeriksaan

Jenis Pemeriksaan

Hasil Pemeriksaan

B. Laboratorium Tanggal

C. Pemeriksaan lainnya Tanggal

Jenis Pemeriksaan

Mengetahui,

Hasil Pemeriksaan

...............................,.......................................

Pembimbing klinik Mahasiswa

(.......................................................)

(............................................................) NIM.

A2. ANALISIS DATA HARI/TGL

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

NO

B. NO

DATA

MASALAH

KEMUNGKINAN PENYEBAB

DIAGNOSA KEPERAWATAN TANGGAL

DIAGNOSA KEPERAWATAN

NAMA & TANDA TANGAN PERAWAT

C. NO

RENCANA TINDAKAN KEPERAWATAN DIAGNOSA KEPERAWATAN

TUJUAN DAN KRITERIA HASIL

INTERVENSI

RASIONAL

NAMA & TANDA TANGAN PERAWAT

NO

DIAGNOSA KEPERAWATAN

TUJUAN DAN KRITERIA HASIL

INTERVENSI

RASIONAL

NAMA & TANDA TANGAN PERAWAT

D.

IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN NO

TANGGAL

JAM

TINDAKAN KEPERAWATAN

NAMA & TANDA TANGAN PERAWAT

E.

EVALUASI TANGGAL

DIAGNOSA NO

KEPERAWATAN

S:

S:

S:

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O:

O:

O:

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A:

A:

A:

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TANGGAL

DIAGNOSA NO

KEPERAWATAN P:

P:

P:

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..............................,....................................... Mengetahui, Pembimbing Klinik

(.......................................................)

Mahasiswa

(............................................................) NIM.