ASUHAN KEPERAWATAN NEONATAL

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

PENGKAJIAN
Tanggal MRS/Jam

Tanggal Pengkajian/Jam

Tempat

DATA SUBYEKTIF
1.

Identitas
Nama Bayi

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

Tanggal/Jam Lahir

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

Jenis Kelamin

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

Umur

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

Dx Medis

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

2.

Keluhan Utama

a) Saat MRS

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

b) Saat Pengkajian

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

3. Identitas Orang Tua

Ayah
Nama
Umur
Suku/Bangsa
Agama
Pendidikan

Ibu

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

No
1
2
3
4
5

: 1 menit/5menit/10 menit/2 jam:

Kriteria

1 menit

5 menit

10 menit

2 jam

Denyut Jantung
Usaha nafas
Tonus otot
Reflek
Warna kulit
TOTAL

6. Pola Fungsi kesehatan

Kebutuhan Dasar
1. Cairan & Makanan
2. Eliminasi
3. Istirahat & Tidur
4. Personal hygiene
5. Aktivitas

7. Status Imunisasi

Saat MRS

Saat Pengkajian

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

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

............................................................................................................................................................................
.........................................................................................................................................
b. Terapi
............................................................................................................................................................................
............................................................................................................................................................................
............................................................................................................................................................................
............................................................................................................................................................................
.........................................................................................................................................
B. ANALISA DATA
..............................................................................................................................................................................................
No

Tanggal / Jam

Analisa Data

Masalah

Etiologi

C. DIAGNOSA KEPERAWATAN
..............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................
D. INTERVENSI
.....................................................................................................................................................................................................
NO

TANGGAL/JAM

KRITERIA HASIL

INTERVENSI

RASIONAL

NO

TANGGAL/JAM

KRITERIA HASIL

INTERVENSI

RASIONAL

E. IMPLEMENTASI
..............................................................................................................................................................................................
NO

TANGGAL/JAM

IMPLEMENTASI

NO

TANGGAL/JAM

IMPLEMENTASI

F. EVALUASI
.................................................................................................................................................................................................
NO

TANGGAL/JAM

EVALUASI

NO

TANGGAL/JAM

EVALUASI