UNIVERSITAS NAHDLATUL ULAMA SURABAYA

Jl. SMEA 57 Surabaya, Tlp. 031-8284508, 8291920, Faks. (031) 8298582

FORMAT PENGKAJIAN NEONATUS

KEPERAWATAN ANAK

Nama Mahasiswa : .. Rumah Sakit : ....

NIM : ...... Ruangan :
Tanggal Pengkajian : .. Jam :

A. IDENTITAS PASIEN
Nama pasien : ..
Umur : ..
Berat badan : ..
Panjang badan : ..
Jenis kelamin : ..
Tanggal lahir : ..
B. IDENTITAS ORANG TUA
Nama ibu : .. Nama Ayah : ...
Umur : .. Umur :
Agama : .. Agama :
Pendidikan : .. Pendidikan :

Pekerjaan : . Pekerjaan :
Alamat : .. Alamat :

C. RIWAYAT KEHAMILAN DAN KELAHIRAN

1. Pre Natal
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2. Intra Natal
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3. Post Natal
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D. KELUHAN UTAMA :
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E. RIWAYAT PENYAKIT SEKARANG
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F. RIWAYAT PENYAKIT KELUARGA
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G. PEMERIKSAAN FISIK
Tanda-tanda vital :
- Nadi :.x/ menit - Respirasi :.x/ menit - Suhu :. C
Pemeriksaan antropometri : - Berat badan : .gram - Panjang Badan : .cm
- Lingkar Kepala :.cm
1. Kepala
a) Kelainan kepala :
( ) Caput succedanum ( ) Cephalhematom
( ) Hidrocephalus ( ) Microcephalus
( ) An encephalus
b) Lain-lain : ..........
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2. Mata
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3. Telinga
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4. Hidung
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5. Mulut
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6. Leher
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7. Dada
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 8. Abdomen
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9. Genetalia
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10. Anus
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11. Kulit
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12. Ekstremitasatas
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13. Ekstremitasbawah
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H. IMUNISASI
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I. PEMERIKSAAN REFLEK PADA BAYI
1. Reflek sucking : ( ) Ada ( ) Tidakada
2. Reflek graps : ( ) Ada ( ) Tidakada
3. Reflek tonic neck : ( ) Ada ( ) Tidak ada
4. Reflek rooting : ( ) Ada ( ) Tidak ada
5. Reflek moro : ( ) Ada ( ) Tidak ada
6. Reflek babinski : ( ) Ada ( ) Tidak ada
7. Reflek menelan : ( ) Ada ( ) Tidak ada

J. APGAR SKOR
Tanda 0 1 2 Setelah 1 Setelah 5
menit menit
Appearance Pucat/ Badan merah, Seluruh tubuh
(warnakulit) seluruhnya ekstremitas kemerah-
biru biru merahan
Pulse Tidak ada < 100 kali/ > 100 kali/
(denyutnadi) menit menit
Grimace Tidak ada Meringis/ Meringis/ batuk/
(reflek) respon menangis bersin saat
terhadap lemah ketika stimulasi
 stimulasi distimulasi salurannafas
Activity Lemah/ Sedikit Gerakanaktif
(tonus otot) Tidak ada gerakan
Respiration Tidak ada Lemah/ tidak Menangis kuat,
(pernafasan) teratur pernafasan baik
dan teratur
Total

K. DATA TAMBAHAN
- HASIL LABORATORIUM
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- HASIL RADIOLOGI
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- OBAT/ TERAPI
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- BALLAD SCORE
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- DOWN SCORE
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- CREMER ICTERUS
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Surabaya, .

Pemeriksa,

(........)
 ANALISA DATA

Nama Pasien :

Umur : tahun/bulan

NO DATA MASALAH ETIOLOGI

( DS/DO)
 DAFTAR DIAGNOSA KEPERAWATAN

NO DIAGNOSA
 TINDAKAN KEPERAWATAN

Nama Pasien :

Umur : tahun/bulan

Tanggal/Jam No. Dx. Per Tindakan

 CATATAN PERKEMBANGAN

Nama Pasien :

Umur : tahun/bulan

Tanggal/Jam No. Dx. Per Perkembangan

E VALU AS I
NamaPasien :

Umur : tahun/bulan

Tanggal/Jam No. Dx. Per Evaluasi