Anda di halaman 1dari 22

FORMAT ASUHAN KEPERAWATAN BAYI BARU LAHIR

ASUHAN KEPERAWATAN PADA By..................


DENGAN.........................................
DI RUANG..........................
RS..
TANGGAL..........

I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama : ............................................
Umur : ............................................
Nama Ibu : ............................................
Umur : ..........................................
Pendidikan : ............................................
Pekerjaan : ............................................
Status perkawinan: ............................................
Agama : ............................................
Suku : ............................................
Alamat : ............................................
No.CM : ............................................
Tanggal MRS : ............................................
Tanggal pengkajian: ............................................
Sumber informasi: ............................................

B. RIWAYAT KELAHIRAN

No Tahun Jenis BB lahir Keadaan Komplikasi Jenis Ket


kelahiran kelamin bayi persalinan
C. RIWAYAT PERSALINAN
BB/TB Ibu : ............kg/................cm Persalinan di...............

Keadaan umum Ibu ......................... Tanda vital .................

Jenis persalinan ............................... Proses persalinan.......

Kala I.................................Jam

Indikasi : ..........................................

Kala II .......................menit
Komplikasi persalinan : Ibu................................. Janin ........................

Lamanya ketuban pecah ...................................... Kondisi ketuban....

D. KEADAAN BAYI SAAT LAHIR


Lahir tanggal : ...................jam............ Jenis kelamin.............

Kelahiran : Tunggal/gemeli

Nilai APGAR
Tanda Nilai Jumlah
0 1 2
Denyut jantung Tidak ada < 100 >100
Usaha napas Tidak ada Lambat Menangis
kuat
Tonus otot Lumpuh Ekstremitas Gerakan aktif
fleksi sedikit
Iritabilitas reflex Tidak Gerakan Reaksi
bereaksi sedikit melawan
Warna Biru/pucat Tubuh Kemerahan
kemerahan,
tangan dan
kaki biru

E. PENGKAJIAN FISIK
Umur ..............Hari....................Jam..........
Berat badan.................................gr
Panjang badan.............................cm
Suhu...........................................C
Lingkar kepala.............................cm
Lingkar dada...............................cm
Lingkar perut..............................cm

Head to toe
Kepala Wajah
o Inspeksi : .............................................................

o Palpasi : .............................................................

Leher
o Inspeksi : .............................................................

o Palpasi : .............................................................

Tubuh
o Warna :

o Lanugo :

o Vernix :

Dada
o Inspeksi : .................................................

o Palpasi : .................................................

o Perkusi : .................................................

o Auskultasi : ..............................................

Abdomen
o Inspeksi :.............................................................

o Auskultasi : ............................................................

o Perkusi :.............................................................

o Palpasi : .............................................................

Punggung
o Keadaan punggung : ...............................................
o Fleksibilitas : ...............................................

o Tulang punggung : ...............................................

o Kelainan : ...............................................

Genetalia dan anus


o Laki-laki : ...............................................

o Perempuan : ..............................................

o Anus : ...............................................

o Mekonium : ...............................................

o Kelainan : ...............................................

Ekstremitas
o Atas : .............................................................

o Bawah : ............................................................

o Kelainan : .............................................................

o Pergerakan : ...........................................................

F. STATUS NEUROLOGI
Pemeriksaan refleks :
G. NUTRISI
ASI/PASI/Lain-lain

H. ELIMINASI
BAB pertama, tanggal ........................ Jam..................
BAK pertama, tanggal ........................ Jam..................

I. DATA PENUNJANG
o Pemeriksaan Laboratorium :..

o Pemeriksaan Diagnostik :..

J. DIAGNOSA MEDIS

K. PENGOBATAN

II. ANALISA DATA


DATA FOKUS ANALISIS MASALAH

Diagnosa keperawatan berdasarkan prioritas :


1. ...................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
.......

2. ...................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
.......
3. ...................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
.......
III. RENCANA KEPERAWATAN

No Tgl / jam Nomo Rencana Keperawatan


r Tujuan Intervensi Rasional
Diagn
osa

















































..









































































IV. IMPLEMENTASI

Tgl/ No. Implementasi Respon Paraf/Nama


Jam Dx

















































































































































































































..

V. EVALUASI

Tgl/Jam No Evaluasi Hasil Paraf


Dx
Tgl/Jam No Evaluasi Hasil Paraf
Dx
Denpasar, .2017
Mengetahui
Pembimbing Klinik/ CI Mahasiswa

(................) (..........)
NIP: NIM:

Clinical Teacher /CT


(...................................................................)
NIP.