SEKOLAH TINGGI ILMU KESEHATAN (STIKES)

(INSTITUTE OF HEALTH SCIENCES)

BANYUWANGI
Kampus 1 : Jl. Letkol Istiqlah 40 Telp. (0333) 421610 Banyuwangi
Kampus 2 : Jl. Letkol Istiqlah 109 Telp. (0333) 425270 Banyuwangi
Website : www.stikesbanyuwangi.ac.id

FORMAT PENGKAJIAN
(Perinatologi)

A. PENGKAJIAN
1. BIODATA
a. Nama Bayi
: ..................................................................
b. Umur/Tanggal lahir : ..................................................................
c. Jenis Kelamin : ..................................................................
d. Nomor Register : ..................................................................
e. Tanggal MRS : ..................................................................
f. Tanggal Pengkajian : ..................................................................
g. Diagnos medis : ..................................................................

PENAGGUNG JAWAB
a. Nama Bayi
: ..................................................................
b. Umur/Tanggal lahir : ..................................................................
c. Jenis Kelamin : ..................................................................
d. Agama : ..................................................................
e. Pekerjaan : ..................................................................
f. Pendidikan terakhir : ..................................................................
g. Status perkawinan
: ..................................................................
h. Suku bangsa : ..................................................................

2. KELUHAN UTAMA / ALASAN MASUK RUMAH SAKIT

a. Keluhan saat MRS
..............................................................................................................
..............................................................................................................
..............................................................................................................
........................
b. Keluhan saat pengkajian
..............................................................................................................
..............................................................................................................
..............................................................................................................
...........................

3. RIWAYAT PENYAKIT SEKARANG

 a. Kronologis penyakit pasien (dirumah, UGD/poli)
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
...........................................................................

4. RIWAYAT PENYAKIT MASA LALU

a. Antenatal (riwayat kehamilan)
 Status GPA : G...P...A...
 Usia kehamilan
: ..................................................................................
 Perawatan antenatal (ANC) : Teratur Tidak teratur
 Tempat pemeriksaan ANC : ………………………………………………
 Penggunaan obat – obatan selama
kehamilan : .......................................
 Imunisasi TT : .........................................................................
 Komplikasi penyakit selama
kehamilan : ................................................

b. Natal (riwayat persalinan sekarang)

 Penolong persalinan
: .............................................................................
 Tempat persalinan
: .............................................................................
 Jenis persalinan
: .............................................................................
 Air ketuban
: ..........................................................................
 Lama persalinan kala
II : ........................................................................
 Keadaan tali pusat
: ..........................................................................

c. Post natal (neonatus)

 APGAR : 1’ dan 5’ : .........................................................................
 Usia gestasi : …………………………………………… (Ballard)
 Resusitasi : ........................................................................
.....
 Pemberian O2 : .........................................................................
 Barat badan lahir : ……… gram; Panjang badan lahir ……. cm
5. RIWAYAT KESEHATAN KELUARGA
a. Genogram (3 generasi)

b. Kesehatan keluarga
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
................................

c. Riwayat psikososial orang tua

1. Pengasuh : Ayah Ibu Nenek Orang
lain
2. Dukungan sibling : Ada Tidak ada
3. Keterlibatan orang tua
 Berkunjung : Ya Tidak
 Kontak mata : Ya Tidak
 Menyentuh : Ya Tidak
 PMK : Ya Tidak
 Berbicara : Ya Tidak
 Menggendong : Ya Tidak

6. RIWAYAT IMUNISASI
...................................................................................................................
...................................................................................................................
...................................................................................................................
........................
7. POLA KEBIASAAN SEHARI-HARI
a. Pola nutrisi
 Jenis
makanan/minuman : ...................................................................
 Frekuensi
: ........................................................................................
 Jumlah : ..................................................................................
..
 Cara
pemberian : ..................................................................................
  Infus/jumlah : ..................................................................................
..

b. Pola eliminasi
BAK
 Frekuensi/
jumlah : .............................................................................
 Warna
: ...................................................................................
BAB
 Frekuensi : ..................................................................................
.
 Warna : ..................................................................................
.
 Konsistensi : ..................................................................................
.

c. Pola istirahat dan tidur

 Lamanya : ..................................................................................
.
 Keadaan waktu
tidur : .........................................................................

8. PEMERIKSAAN FISIK
a. Keadaan umum
..............................................................................................................
..............................................................................................................
..............................................................................................................
........................
b. Tanda – tanda vital
Nadi : .......................................
RR : ...............................................
Suhu : .....................................
c. Satus gizi / pertumbuhan
 Berat badan
: ....................................................................................
 Panjang badan
: ....................................................................................
 Lingkar lengan
: ....................................................................................
 Lingkar dada
: ......................................................................................
 Lingkar kepala
: ....................................................................................
d. Pemeriksaan cepalo caudal
1. Kepala dan rambut
 Caput Succedenum
: ........................................................................
 Chepal hematoma
: ........................................................................
 Fontanela :
Lunak Datar Menonjol Cekung
 Sutura sagitalis
Tepat Terpisah Menjauh Tumpang
tindih
 Gambaran wajah :
Simetris Asimetris

2. Mata
 Bentuk/simetris : ..........................................................................
... ….
 Kotoran : ..................................................................................
.
 Konjungtiva : .........................................................................
..........
 Sklera : ..................................................................................
...........
 Palpebra : ..................................................................................
.
 Jarak interkantus : …………………….. cm

3. Hidung
 Lubang
hidung : ................................................................................
 Pernapasan cuping
hidung : ...............................................................
 Sekret
: ......................................................................................
 Kelainan : ..................................................................................
..
 Refleks
grabella : ................................................................................

4. Telinga
 Bentuk : ..................................................................................
..
 Letak telinga terhadap
mata : .............................................................
 Pengeluaran
cairan : ..........................................................................
  Kelainan : ..................................................................................
.
 Refleks startel
: ...................................................................................
5. Rongga mulut dan tenggorokan
 Warna bibir
: .......................................................................................
 Palatum : ..................................................................................
...
 Lidah
: ......................................................................................
 Gigi : ..................................................................................
...
 Refleks
sucking : .................................................................................
 Refleks
rooting : ...................................................................................
 Refleks
gawn : ....................................................................................

6. Leher
 Pembengkakan
kelenjar : ...................................................................
 Kelenjar tiroid : .........................................................................
 Reflek tonik neck
: .........................................................................
 Kelainan : .........................................................................

7. Dada/thorak
a. Pemeriksaan paru
1. Inspeksi
................................................................................................
................................................................................................
...............
2. Palpasi
................................................................................................
................................................................................................
...........
3. Perkusi
................................................................................................
................................................................................................
...........
4. Auskultasi
 ................................................................................................
................................................................................................
...........
Down score
Nilai 0 1 2
Frekuensi nafas < 60x/menit 60-80x/menit >80x/menit
Retraksi Tidak ada Retraksi ringan Retraksi berat
Sianosis Tidak ada Hilang dengan O2 Menetap dengan O2
Air entry (udara Ada Menurun Tidak terdengar
masuk)
Merintih Tidak ada Terdengar dengan Terdengar tanpa
stesokop alat bantu
Ket: Skor < 4 : gangguan pernapasan ringan
Skor 4-5 : gangguan pernapasan sedang
Skor > 6 : gangguan pernapasan berat (pemeriksaan AGD harus
dilakukan)

b. Pemeriksaan jantung
1. Inspeksi
................................................................................................
................................................................................................
...............
2. Palpasi
................................................................................................
................................................................................................
............
3. Perkusi
................................................................................................
................................................................................................
............
4. Auskultasi
................................................................................................
................................................................................................
...........

8. Abdomen
1. Inspeksi
 Keadaan tali pusat
: ..................................................................
 Perdarahan tali pusat
: ..................................................................
 Tanda – tanda infeksi
: ................................................................
 Hernia umbilikalis
: ...................................................................
 Kelainan : ...............................................................
..
 2. Auskultasi
.....................................................................................................
.....................................................................................................
............
3. Palpasi
.....................................................................................................
.....................................................................................................
...........
4. Perkusi
.....................................................................................................
.....................................................................................................
................

9. Ekstrimitas
 Gerakan
: ..........................................................................
 Reflek grasping
: ...........................................................................
 Refleks moro
: .....................................................................................
 Refleks grasping
: ...........................................................................
 Refleks menari
: ..........................................................................
 Jari-jari tangan
: ..........................................................................
 Akrosianosis : ...............................................................
............
 Kelainan tulang : Tidak ada Ada, sebutkan
…………………
 Tonus otot : ………………………………………………………..

10. Genetalia dan anus

1. Laki-laki
 Lubang uretra
: .............................................................................
 Testis : .........................................................................
.
 Lubang anus
: ..........................................................................
2. Perempuan
 Labia mayora
: .............................................................................
 Lubang vagina
: ..........................................................................
  Lubang uretra
: ...........................................................................
 Lubang anus
: ..........................................................................

11. Keadaan punggung

 Spina bifida
: .................................................................................
 Refleks
peres : .................................................................................

12. Integumen
 Warna kulit
: ..................................................................................
 Sianosis : Pada kuku Pada sekitar mulut
Ekstrimitas atas Ekstrimitas bawah
Seluruh tubuh
 Kemerahan (rash) : Ada Tidak ada
 Tanda lahir
: ...................................................................................
 Turgor kulit :
……………………………………………………………...
 Kelainan : ..................................................................................
.

13. Skrining nyeri

Tidak ada
Ada, bila ya lampirkan da nisi formulir penilaian nyeri pada
neonatus

9. PEMERIKSAAN PENUNJANG
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10. PENATALAKSANAAN
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Banyuwangi,..........................
20…
Mahasiswa
 ANALISA DATA

Nama Pasien : …………………………………………

No. Register : …………………………………………

NO KELOMPOK DATA MASALAH ETIOLOGI

 DAFTAR DIAGNOSA KEPERAWATAN

Nama Pasien : …………………………………………

No. Register : …………………………………………

TANGGAL TANGGAL TANDA

DIAGNOSA KEPERAWAT AN
MUNCUL TERATASI TANGAN
 RENCANA ASUHAN KEPERAWAT AN

Nama Pasien : …………………………………………

No. Register : …………………………………………

TGL NO TUJUAN KRITERIA HASIL INTERVENSI RASIONAL PT

 CATATAN KEPERAWAT AN

Nama Pasien : …………………………………………

No. Register : …………………………………………

NO.
TANGGAL JAM TINDAKAN KEPERAWATAN PT
DX
 CATATAN PERKEMBANGAN

Nama Pasien : …………………………………………

No. Register : …………………………………………

NO TANGGAL TANGGAL TANGGAL