FORMAT PENGKAJIAN

KEPERAWATAN NEONATUS
NAMA MAHASISWA
: __________________________________________________________
NIM
: __________________________________________________________
RUANG PRAKTEK
: __________________________________________________________
TANGGAL PRAKTEK
: __________________________________________________________
TANGGAL PENGKAJIAN : __________________________________________________________
I. IDENTITAS DATA
1.
Nama
2.
Tanggal Lahir
3.
Nama Ayah
4.
Nama Ibu
5.
Pekerjaa Ayah/ Ibu
6.
Alamat
7.
Agama
8.
Pendidikan Ayah/ Ibu
9.
Kultur

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: ____________________________________________________
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II. KELUHAN UTAMA

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III. RIWAYAT KEHAMILAN DAN KELAHIRAN

a. Prenatal
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b. Natal
:
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c. Postnatal
:
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IV. RIWAYAT KESEHATAN KELUARGA

:
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Program Diploma III Keperawatan UMM 2006/2007

V. KEBUTUHAN DASAR
a. Cairan
b. Makanan/Minum
c. Pola Tidur

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VI. KEADAAN KESEHATAN SAAT INI

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a. Diagnosa Medis
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b. Tindakan operasi
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c. Status nutrisi
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d. Status cairan
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e. Obat-obatan
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f. Aktifitas
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g. Tindakan Keperawatan
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h. Pmx Radiologi
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i. Lain-lain
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VII. PEMERIKSAAN FISIK

a. Pengukuran Umum
Lingkar kepala

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:
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Lingkar dada

Panjang kepala ke tumit : ____________________________________________________

BB Lahir

b. Tanda Vital
Suhu Aksila

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Frekuensi jantung

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Pernafasan

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Tekanan darah

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c. Penampilan Umum
Postur

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d. Kulit
Warna kulit saat lahir

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Vernik kaseosa

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Lanugo

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Edema

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Perubahan warna kulit : ____________________________________________________

e. Kepala
Fontanel anterior

Fontanel posterior

f. Mata
Kelopak mata

Warna kelopak mata

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Program Diploma III Keperawatan UMM 2006/2007

Air mata

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Reflek kornea

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Reflek pupil

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Reflek berkedip

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Fiksasi rudimenter

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g. Telinga
Posisi puncak pinna

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Reflek morro

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Kartilago

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h. Hidung
Patensi natal

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Rabas nasal

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Bersin

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i. Mulut dan Tenggorok

Palatum arkus

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Uvula

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Frenulum lidah

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Frenulum bibir atas

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Reflek menghisap

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Reflek rooting

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Reflek gag

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Reflek ekstrusi

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Menangis

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Saliva

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j. Leher
Bentuk

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: ____________________________________________________

Refleks leher tonik

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Refleks neck-righting

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Refleks otolith-righting : ____________________________________________________

k. Dada
:
Diameter anteroposterior
dan lateral
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Retraksi sternal
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Prosesus xifoideus

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Pembesaran dada

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l. Paru-paru
Pernafasan

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: ____________________________________________________

Reflek batuk

Bunyi nafas bronchial : ____________________________________________________

: ____________________________________________________

Program Diploma III Keperawatan UMM 2006/2007

m. Jantung
Letak apeks

Bunyi jantung

n. Abdomen
Bentuk

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Palpasi hepar

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Palpasi limpa

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Palpasi ginjal

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Pusat umbilicus

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Nadi femoralis

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o. Genetalia Wanita
Labia minora

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Malia mayora

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Klitoris

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Meatus uretral

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Vernik kaseosa

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Frekuensi berkemih

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p. Genetalia Pria
Lubang uretra

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Testis

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Skrotum

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Frekuensi berkemih

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q. Punggung dan Rectum

Pemeriksaan spina

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Wink anal

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Lubang anal

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Pengeluaran mekonium : ____________________________________________________

Pengeluaran feces

r. Extremitas
Bentuk

: ____________________________________________________
:
: ____________________________________________________

Jumlah jari-jari

: ____________________________________________________

Rentang gerak

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Warna punggung kuku : ____________________________________________________

Bentuk Telapak tangan

dan kaki
: ____________________________________________________
Tonus otot
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Nadi brachialis

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s. Kelaianan Sistem Neuromuskuler

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Tremor
: ____________________________________________________

Kedutan

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Program Diploma III Keperawatan UMM 2006/2007

Tanda paralysis

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Postur opistotonik

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Hipotonia

: ____________________________________________________

Hipertonia

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VIII. PEMERIKSAAN PENUNJANG

a. Pemeriksaan laboratorium : ____________________________________________________
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b. Lain-lain

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Program Diploma III Keperawatan UMM 2006/2007