I.

Pemeriksaan Fisik
Keadaan umum
Kesadaran
Tanda Vital

= Aktif
= baik
= Nadi 120 x/ menit Suhu : 36,3 C RR : 50..x/ menit
Saat lahir
2800
-

Berat badan
Panjang badan
Lingkar kepala

Saat ini
3000
48
36

Beritanda (cek) padaistilah yang tepatdari data - data dibawahini.Gambarkansemuatemuan

abnormal secaraobyektif, gunakankolomkomentarberikut:
1.

Refleks
( v ) Moro

2.

( v ) Menggenggarn

( v) Mengisap

Tonus /aktivitas

a.

( v )Aktif

( ) Tenang

b.

( v) Menangiskeras

( ) letargi

( ) Lemah

( ) Kejang

( ) Melengking

) Sulitmenangis

3. Kepala / leher
Fontanel anterior

a.

( ) Lunak

( ) Tegas

( v ) Datar

) Menonjol

) Cekung

Suturasagitalis

b.

( v ) Tepat

( ) Terpisah

c. Gambaranwajah( v ) Simetris
Molding

d.

( ) Menjauh

( ) Asimetris

( ) Caput succedaneum

4. Mata

( v ) bersih

( ) Chepalohematoma

( ) Sekresi.

5. THT :
a. Telinga

( v ) Normal

b. Hidung

)Abnormal

( v ) Bilateral

c. Palatum

( v ) Normal

( )Obstruksi

( )CupingHidung

( ) abnormal

6. Abdomen
a. (

) Lunak

b. Lingkarperut :
c. Liver

) Tegas

( v ) Datar

33 cm
( v ) kurangdari 2 cm

7. Toraks
a. ( v ) simetris
b. Retraksi

c. Klavikula :

) asimetris

( ) derajat I

8. Paru- paru

) Normal

( ) Kembung

) derajat 2
) abnormal

( ) derajat 3

( ) Lebihdari 2 cm

a. Suaranafas : ( v ) samakanankiri
(

) bersih

) ronchi

( ) tidaksamakanankiri

( ) rales

) secret

b. Bunyinapas ( v ) terdengarpadasemualapangparu(

) menurun ( ) tdkada

Respirasi

c.

) Spontan,

50

Jumlah :x/menit

) Sungkup/boxhead, Jumlah : x/menit

) ventilasi assisted CPAP

9. Jantung
a. Bunyi Normal Sinus Rytrm. ( NS R) , jumlah.. x/mntt
Mur- mur

( ) Lain-lain, sebutkan..................................

b. Waktupengisiankapasitas :
Batangtubuh ... ... ... ... ... ... ... ... ... ... ... ... .........
Ekstrimitas
c. Nadiperifer
Berat

Lemah

Tidakada

Brakhial -kanan
Brakhial kiri
Femoral - kanan
Femoral kiri
10. Ekstrimitas
( v ) semuaekstremitasbergerak (

) ROM terbatas (

) tidakdapatdikaji

Ekstremitasatas&bawah
( v ) Simetris(

) Asimetris

11. Umbilikus
( v ) Normal
(

) Inflamasi

(
(

) Abnormal
) Drainase

12. Genital

) Perempuan

( v ) Laki-laki normal

13. Anus

( v ) Paten

) Imperforata

14. Spina

( v ) Normal

) Abnormal

15. Kulit
a. Warna

( ) Pink

b. (

) Rash/ kemerahan

c. (

) Tandalahir

16. Suhu
a. Lingkungan

( v ) Pucat

( v ) Jaudice

) ambivalen

) Penghangat radian

) Pengaturansuhu

) Inkubator

( v ) suhuruang

( v ) Boksterbuka

b. Suhukulit : 36,3
Komentar :
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II.

III.

Informasi Lain
By. Dirawat di RS. Ulin pada tanggal 28 Nop 2013, pada saat pengkajian usia bayi 34
hari.
Ringkasan Riwayat Kesehatan
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