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PENGKAJIAN
Tanggal MRS/Jam :
Tanggal Pengkajian/Jam :
Tempat :
A. DATA SUBYEKTIF
1. Identitas
Umur :...............................................................................................................................
Dx Medis :................................................................................................................................
2. Keluhan Utama
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3. Identitas Orang Tua
Ayah Ibu
Nama : :
Umur : :
Suku/Bangsa : :
Agama : :
Pendidikan : :
Pekerjaan : :
Alamat : :
4. Riwayat Prenatal
- Kehamilan ke :....................................................................................................................
- Imunisasi TT :.....................................................................................................................
4. Riwayat IntraNatal
- Persalinan ke :..........................................................................................................
1 Denyut Jantung
2 Usaha nafas
3 Tonus otot
4 Reflek
5 Warna kulit
TOTAL
2. Eliminasi
4. Personal hygiene
5. Aktivitas
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 : ....................................................................................................................................................
Abdomen : ....................................................................................................................................................
Punggung : ....................................................................................................................................................
Ekstermitas : ....................................................................................................................................................
Genitalia : ....................................................................................................................................................
Anus : ....................................................................................................................................................
3. Pemeriksaan Neurologis
Moro : ....................................................................................................................................................
Rooting : ....................................................................................................................................................
Sucking : ....................................................................................................................................................
Swallowing : ....................................................................................................................................................
Walking : ....................................................................................................................................................
Graphs : ....................................................................................................................................................
Tonicneck : ....................................................................................................................................................
Burning : ....................................................................................................................................................
5. Pemeriksaan Penunjang
a. Pemeriksaan Laboratorium
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b. Terapi
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6. DIAGNOSA KEPERAWATAN
7. INTERVENSI
8. IMPLEMENTASI
9. EVALUASI