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ASUHAN KEPERAWATAN NEONATAL

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

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b) Saat Pengkajian :………………..........................................................................................................

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

- Nilai APGAR : 1 menit/5menit/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


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
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b. Terapi
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