PENGKAJIAN KEPERAWATAN NEONATUS

I.

IDENTITAS DATA
Nama
Tempat / Tanggal lahir
Nama Ayah/lbu
Pekerjaan Ayah
Pendidikan Ayah
Pekerjaan lbu
Pendidikan Ibu
Alamat
Kultur
Agama
Tanggal Pengkajian

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

II. KELUHAN UTAMA

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
Riwayat Penyakit Sekarang :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
Riwayat Penyakit Dahulu :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

III.
RIWAYAT KEHAMILAN& KELAHIRAN
1. Prenatal
- Jumlah kunjungan
= ..
- Bidan/dokter
= ..
- Penkes yang didapat
= ..
..
..
- HPHT
= ..
- Kenaikan BB selama hamil
= ..
- Komplikasi kehamilan
= ..
- Komplikasi obat
= ..
- Obat-obatan yang didapat
= ..
- Riwayat hospitalisasi
= ..
- Golongan darah ibu
= ..
- Pemeriksaan kehamilan/Maternal screening
( ) Rubella ( ) Hepatitis ( ) CMV ( ) GO ( ) Herpes
( ) HIV
( ) lain-lain; sebutkan
Usia Kehamilan
= ..
Masa Gestasi
= ..
2.
-

Natal
Awal persalinan
= .....................................................................
Lama persalinan
= .....................................................................
Komplikasi persalinan
= .....................................................................
Terapi yang diberikan = .....................................................................
Cara melahirkan
= .....................................................................
( ) Pervaginam
( ) Caesar
( ) Lain-lain, sebutkan ............................................
3. Post natal
Usaha nafas
( ) dengan bantuan
( ) tanpa bantuan
Kebutuhan resusitasi
Jenis dan lamanya dari 1 dan 5 menit
= ...............................
skor Apgar
= ................................

Obat-obatan yang diberikan pada neonatus

Nama Obat
Dosis
................................... ...................................
.
.
................................... ...................................
................................... ...................................
................................... ...................................
.
.
................................... ...................................
................................... ...................................
................................... ...................................
.
.
................................... ...................................
................................... ...................................
................................... ...................................
.
.
................................... ...................................
................................... ...................................
................................... ...................................
.
.
................................... ...................................
................................... ...................................
................................... ...................................
.
.
................................... ...................................
................................... ...................................
................................... ...................................
.
.
................................... ...................................
................................... ...................................
................................... ...................................
.
.
................................... ...................................
................................... ...................................
................................... ...................................
.
.
................................... ...................................
................................... ...................................
................................... ...................................
.
.

Indikasi
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................

...................................
...................................

...................................
...................................

Interaksi orang tua dan bavi

Kualitas
= ...............................................................................................
Lamanya
=..............................................................................................

Trauma lahir
( ) ada
( ) tidak
Narkosis
( ) ada
( ) tidak
Keluar urin/feses
( ) ada
( ) tidak
Respon fisiologis atau perilaku yang bermakna
................................................................................................................................................
................................................................................................................................................
...............................................................................................................................................

I V. RIWAYAT KESEHATAN KELUARGA

GENOGRAM

V.

RIWAYAT SOSIAL

1. Sistem pendukung/ keluarga terdekat yang dapat dihubungi

............

2. Hubungan orang tua & bayi :

Ibu
Ayah
Memeluk
Berbicara
Berkunjung
Kontak mata
Menyentuh
3. Anak yang lain
Jenis Kelamin anak

Riwayat Persalinan

Riwayat Imunisasi

4. Lingkungan rumah

5. Problem sosial yang penting

VI.

KEADAAN KESEHATAN SAAT INI

1. Diagnosis Medis

2. Tindakan Operasi

3. Status Nutrisi

4. Status Cairan

5. Obat- obatan
Nama Obat
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................

Dosis
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................
.
...................................
...................................
...................................

Indikasi
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................
....................................
...................................
...................................

.
...................................
...................................

.
...................................
...................................

6. Aktivitas

7. Tindakan Keperawatan yang Telah Dilakukan

8. Hasil Laboratorium (tanggal :

Jenis Pemeriksaan
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................

)
Hasil
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................

Interpretasi
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....

..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................

.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................

................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....

..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................

..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................

................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....

..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..
............................................
..

.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.
..................................
..
..................................
.
..................................
.

................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....
................................
.....

9. Pemeriksaan Penunjang

10. Lain-lain

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

PEMERIKSAAN FISIK
Keadaan umum
=
Kesadaran
=
Tanda Vital
Nadi
: x/ menit
Suhu
: C
RR
: ..x/ menit
Saat lahir
Berat badan
Panjang badan
Lingkar kepala

GCS:

Saat ini

Beri tanda (cek) pada istilah yang tepat dari data-data dibawah ini.
Gambarkan semua temuan abnormal secara objektif, gunakan kolom
komentar berikut:

a.
b.

d.

a.
b.
c.

1. Refleks
( ) Moro
( ) Menggenggarn ( ) Mengisap
2. Tonus /aktivitas
( ) Aktif
( ) Tenang
( ) Letargi
( ) Kejang
( ) Menangis keras
( ) Lemah
( ) Melengking
( ) Sulitmenangis
3.Kepala / leher
a. Fontanel anterior
( ) Lunak
( ) Tegas
( ) Datar
( ) Menonjol
( ) Cekung
b. Sutura sagitalis
( ) Tepat
( ) Terpisah ( ) Menjauh
c. Gambaran wajah
( ) Simetris
( ) Asimetris
Molding
( ) Caput succedaneum
( ) Chepalohematoma
4. Mata
( ) Bersih
( ) Sekresi .
5. THT
a. Telinga
( ) Normal
( )Abnormal
b. Hidung
( ) Bilateral
( )Obstruksi
( )Cuping Hidung
c. Palatum
( ) Normal
( ) abnormal
6. Abdomen
a. ( ) Lunak
( ) Tegas
( ) Datar
( ) Kembung
b. Lingkar perut :
cm
c. Liver
:( ) Kurang dari 2 cm
( ) Lebih dari 2 cm
7. Toraks
( ) Simetris
( ) Asimetris
Retraksi
: ( ) Derajat 1 ( ) Derajat 2 ( ) Derajat 3
Klavikula
: ( ) Normal
( ) Abnormal
8. Paru- paru
a. Suara napas :
( ) Sama kanan kiri ( ) Tidak sama kanan kiri
( ) Bersih
( ) Ronchi ( ) Rales ( ) Sekret
b. Bunyi napas

( ) Terdengar padasemua lapang paru

( ) Menurun
( ) Tidakada
c. Respirasi
( ) Spontan,
Jumlah :
x/menit
( ) Sungkup/boxhead,
Jumlah :
x/menit
( ) Ventilasi assisted CPAP
9. Jantung
a. Bunyi Normal Sinus Rythm. (NS R),jumlah ..x/mnt
( ) Mur- mur ( ) Lain-lain
b. Nadi perifer
Berat
Lemah
Tidakada
Brakhialkanan
Brakhial kiri
Femoral kanan
Femoral kiri

10. Genital
( ) Perempuan

( ) Laki-laki

( ) Ambivalen

11. Anus
( ) Paten
( ) Imperforata
12. Ekstremitas
( ) Semua ekstremitas bergerak
( ) ROM terbatas
( ) Tidak dapat dikaji
Ekstremitas atas & bawah ( ) Simetris( ) Asimetris
13. Umbilikus
( ) Normal
( ) Abnormal
( ) Inflamasi
( ) Drainase
( ) Abnormal
14. Kulit
a. Warna
( ) Pink
( ) Pucat
( ) Jaundice
b. ( ) Rash/ kemerahan
c. ( ) Tanda lahir
15. Suhu
a. Lingkungan
( ) Penghangat radian
( ) Pengaturan suhu
( ) Inkubator
( ) suhu ruang

( ) Boksterbuka
b. Suhu kulit : .C
Komentar :

VIII. PEMERIKSAAN TINGKAT PERKEMBANGAN/REFLEKS

PRIMITIF
1. Kemandirian dalam bergaul
...
2. Motorik halus
...
...
...

3. Kognitif dan bahasa

..
..

..
..

4. Motorik kasar

....
..
..

Kesimpulan Perkembangan :
( ) Menangis bila tidak nyaman
( ) Membuat suara tenggorok yang pelan
( ) Memandang wajah dengan sungguh-sungguh
( ) Mengeluarkan suara

(
(
(
(
(
(

) Berespon secara berbeda terhadap objek yang berbeda

) Dapat tersenyum
) Menggerakkan kedua lengan&tungkai sama mudahnya ketika
telentang
) Memberikan reaksi ketika melihat kearah sumber cahaya
(misalnya lampu senter yang digerakkan kanan&kiri)
) Mengoceh&memberikan reaksi suara
) Membalas senyuman

IX. INFORMASI LAIN

ANALISA DATA
No
.

Data (Symptom)
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.

Penyebab

Masalah

(Etiologi)

(Problem)

...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.
...............................................................................
.

...............................................................................
.
...............................................................................
.
...............................................................................
...............................................................................
.
PRIORITAS MASALAH
1
2
3...
RENCANA INTERVENSI
No

Diagnosa

NOC

NIC

..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..

..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..

..
..
..
..
..
..
..
..
..
..
..
..
..
..
..

..
..
..
..
..
..
..
..
..
..
..
..
..
..
..

IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN

No.
Dx
Kep

Waktu
Tgl/jam

Tindakan
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.

TT

Waktu
Tgl/jam

Catatan Perkembangan
(SOAP)
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................
........................................................................

TT

....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.
....................................................................
.