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FORMAT ASUHAN KEPERAWATAN PADA BAYI BARU LAHIR

PENGKAJIAN
Tanggal MRS / Jam : ……………………………………………………….
Tanggal Pengkajian / Jam : ……………………………………………………….
Tempat : ……………………………………………………….

A. DATA SUBJEKTIF
1. IDENTITAS
Nama Bayi : ……………………………………………………….
Tanggal / Jam lahir : ……………………………………………………….
Jenis Kelamin : ……………………………………………………….
Umur : ……………………………………………………….
Dx Medis : ……………………………………………………….
Identitas Orang Tua : ……………………………………………………….
Ayah Ibu

Nama ……………………………. ………………………………..


Umur ……………………………. ………………………………..
Suku / Bangsa ……………………………. ………………………………..
Agama ……………………………. ………………………………..
Pendidikan ……………………………. ………………………………..
Pekerjaan ……………………………. ………………………………..
Alamat ……………………………. ………………………………..

2. KELUHAN UTAMA
a. Saat MRS : ……………………………………………………….
b. Saat Pengkajian : ……………………………………………………….

3. RIWAYAT PRENATAL
a. Kehamilan Ke : ……………………………………………………….
b. Tempat ANC : ……………………………………………………….
c. Imunisasi TT : ……………………………………………………….
d. Obat-obatan yang pernah diminum selama hamil :
…………………………………………………………………………………..
e. Penerimaan ibu/keluarga terhadap kehamilan :
…………………………………………………………………………………..
f. Masalah yang pernah dialami ibu saat hamil :
…………………………………………………………………………………..

4. RIWAYAT INTRANATAL
a. Persalinan ke : ……………………………………………………….
b. Tempat dan Penolong persalinan : ……………………………………………..
c. Masalah saat persalinan : ……………………………………………………….
d. Jenis persalinan : ……………………………………………………….
e. Lama persalinan : ……………………………………………………….
f. Keadaan bayi saat lahir : ……………………………………………………….
g. Segera menangis/tidak : ……………………………………………………….

5. RIWAYAT NATAL
a. Keadaan bayi baru lahir : ……………………………………………………….
b. Lahir tanggal dan jam : ……………………………………………………….
c. Masa gestasi : …………………………………………………minggu
d. BB/PB lahir : ……………………………………………………….
e. Nilai APGAR : 1 menit / 5 menit / 10 menit / 2 jam
No Kriteria 1 menit 5 menit 10 menit 2 jam
1. Denyut jantung
2. Usaha nafas
3. Tonus otot
4. Reflek
5. Warna kulit
TOTAL
6. POLA FUNGSI KESEHATAN
Kebutuhan Dasar Saat MRS Saat Pengkajian
Cairan dan makanan
Eliminasi
Istirahat dan tidur
Personal hygiene
Aktivitas

7. STATUS IMUNISASI
………………………………………………………………………………………
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B. DATA OBJEKTIF
1. PEMERIKSAAN UMUM
a. Keadaan Umum : …………………………… Kesadaran : ……………………
b. Tanda vital :
Nadi : ……………………………………………………………….
RR : ……………………………………………………………….
Suhu : ……………………………………………………………….

2. PEMERIKSAAN ANTOPOMETRI
a. BB : ……………………………………………………………….
b. PB : ……………………………………………………………….
c. LK : ……………………………………………………………….
d. LD : ……………………………………………………………….
e. LLA : ……………………………………………………………….
3. PEMERIKSAAN FISIK
a. Kepala : ……………………………………………………………….
b. Muka : ……………………………………………………………….
c. Ubun-ubun : ……………………………………………………………….
d. Mata : ……………………………………………………………….
e. Hidung : ……………………………………………………………….
f. Telinga : ……………………………………………………………….
g. Mulut : ……………………………………………………………….
h. Leher : ……………………………………………………………….
i. Dada : ……………………………………………………………….
j. Tali pusat : ……………………………………………………………….
k. Abdomen : ……………………………………………………………….
l. Punggung : ……………………………………………………………….
m. Ekstremitas : ……………………………………………………………….
n. Genetalia : ……………………………………………………………….
o. Anus : ……………………………………………………………….

4. PEMERIKSAAN NEUROLOGIS
a. Moro : ……………………………………………………………….
b. Rooting : ……………………………………………………………….
c. Sucking : ……………………………………………………………….
d. Swallowing : ……………………………………………………………….
e. Walking : ……………………………………………………………….
f. Graphs : ……………………………………………………………….
g. Tonicneck : ……………………………………………………………….
h. Burning : ……………………………………………………………….
5. PEMERIKSAAN PENUNJANG

Pemeriksaan Laboratorium

No
6. TERAPI MEDIS
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C. ANALISA DATA

No Data Etiologi Masalah


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D. DIAGNOSA KEPERAWATAN
No Diagnosa TTD
E. INTERVENSI
No Diagnosa NOC NIC
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No Diagnosa NOC NIC
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F. IMPLEMENTASI DAN EVALUASI KEPERAWATAN
No Dx Impelementasi Evaluasi
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No Dx Impelementasi Evaluasi
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