PENGKAJIAN KEPERAWATAN

1. IDENTITAS

a. Perawat Yang Mengkaji

Nama : ........................................................................................................................

Tanggal Pengkajian : ........................................................................................................................

Jam Pengkajian : ........................................................................................................................

b. Pasien

Nama : ........................................................................................................................

Umur : ........................................................................................................................

Agama : ........................................................................................................................

Pendidikan : ........................................................................................................................

Pekerjaan : ........................................................................................................................

Status : ........................................................................................................................

Alamat : ........................................................................................................................

Tanggal Masuk : ........................................................................................................................

Diagnosa Medis : ........................................................................................................................

c. Penanggung Jawab

Nama : ........................................................................................................................

Umur : ........................................................................................................................

Agama : ........................................................................................................................

Pendidikan : ........................................................................................................................

Pekerjaan : ........................................................................................................................

Status : ........................................................................................................................

Alamat : ........................................................................................................................

Hub. Dengan Pasien : ........................................................................................................................

2. KELUHAN UTAMA

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3. KELUHAN YANG MENYERTAI

a. ........ ......................................................................................................................................................

b. …… .........................................................................................................................................................

c. …… .........................................................................................................................................................

d. .. ............................................................................................................................................................

4. RIWAYAT KESEHATAN

a. Alasan Masuk Rumah Sakit / Puskesmas

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b. Riwayat Penyakit Saat Ini

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c. Riwayat Penyakit Dahulu

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d. Riwayat Penyakit Keluarga

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 e. Riwayat Sosial

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5. RIWAYAT PRENATAL

a. GPA

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b. Riwayat Menstruasi, HPHT dan TP

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c. Riwayat Perkawinan

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d. Masalah Yang Timbul Apabila Ibu Hamil

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e. Penyakit Dalam Kehamilan Yang Lalu

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 f. Masalah Dalam Persalinan Yang Lalu

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g. Penggunaan Alat Kontrasepsi Sebelumnya

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6. RIWAYAT PEMERIKSAAN KEHAMILAN

a. Trimester 1

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b. Trimester 2

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c. Trimester 3

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7. IMUNISASI

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8. RIWAYAT PERSALINAN DAN KELAHIRAN SAAT INI

a. Proses Persalinan

1) Kala I

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2) Kala II

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3) Kala III

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4) Kala IV

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 b. Posisi Bayi Saat Lahir

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c. Penggunaan Obat Saat Persalinan

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d. Masalah Yang Timbul Selama Persalinan

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9. DATA BAYI SAAT INI

a. Keadaan Umum Bayi Baru Lahir

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1) Berat Badan

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2) Panjang Badan

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3) Lingkar Kepala

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4) Lingkar Dada
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5) Lingkar Perut

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6) Lingkar Lengan Atas

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7) Jenis Kelamin

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b. Apgar Score

No APGAR 0 1 2 POIN
1 Warna Kulit Pucat Badan Merah, Seluruh Tubuh
Ekstrimitas Biru Kemerahan
2 Denyut Jantung Tidak Ada < 100 x/menit ≥ 100 x/menit
3 Pernapasan Tidak Ada Lemah, Tidak Teratur Baik, Menangis
4 Reflex, Reaksi Tidak Ada Sedikit Gerakan Batuk, Bersin
Mimik
5 Tonus Otot Tidak Ada Ekstrimitas Dalam Gerakan Aktif
Sedikit Fleksi
TOTAL
Keterangan :

0–3 = Asfiksia Berat

4–6 = Asfiksia Sedang

7 – 10 = Baik

10.KEADAAN UMUM

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11.PEMERIKSAAN VITAL SIGN

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12.PEMERIKSAAN FISIK

a. Pemeriksaan Head To Toe

1) Kepala

Inspeksi : ..................................................................................................................................

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Palpasi : ..................................................................................................................................

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2) Mata

Inspeksi : ..................................................................................................................................

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Palpasi : ..................................................................................................................................

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3) Telinga

Inspeksi : ..................................................................................................................................

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Palpasi : ..................................................................................................................................
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4) Hidung

Inspeksi : ..................................................................................................................................

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Palpasi : ..................................................................................................................................

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5) Mulut

Inspeksi : ..................................................................................................................................

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Palpasi : ..................................................................................................................................

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6) Leher

Inspeksi : ..................................................................................................................................

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Palpasi : ..................................................................................................................................

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7) Dada / Thoraks

Inspeksi : ..................................................................................................................................
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Palpasi : ..................................................................................................................................

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Perkusi : ..................................................................................................................................

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Auskultasi : ..................................................................................................................................

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8) Abdomen

Inspeksi : …………. ......................................................................................................................

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Auskultasi : …… ............................................................................................................................

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Palpasi : …………. ......................................................................................................................

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Perkusi : …… ............................................................................................................................

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9) Genetalia, Obstetri, dan Ginekologi

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10) Rectum

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11) Ekstrimitas

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12) Psikososial dan Spiritual

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b. Basic Promothing Phisiology Of Health

1) Oksigenasi

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2) Aktifitas dan Latihan

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3) Tidur dan Istirahat

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4) Kenyamanan dan Nyeri

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5) Nutrisi / Makanan

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6) Cairan Elektrolit dan Asam Basa

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7) Eliminasi

a. BAB

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b. BAK

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 8) Personal Hygiene

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9) Sensori Persepsi, Kognitif

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13. PEMERIKSAAN PENUNJANG

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14.THERAPY MEDIS

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 KLASIFIKASI DATA

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 PATHWAY

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 ANALISA DATA

NO DATA ETIOLOGI MASALAH

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DIAGNOSA KEPERAWATAN

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 INTERVENSI KEPERAWATAN

NO KODE NOC NIC

DX

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 IMPLEMENTASI DAN EVALUASI

NO HARI / IMPLEMENTASI JAM EVALUASI

TGL

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 DAFTAR PUSTAKA

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 INTERVENSI KEPERAWATAN

NO KODE NOC NIC

DX

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 IMPLEMENTASI DAN EVALUASI

NO HARI / IMPLEMENTASI JAM EVALUASI

TGL

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 ANALISA DATA

NO DATA ETIOLOGI MASALAH

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