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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 Orang Tua
: ..................................................................
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
: .......................................................................
 Penggunaan obat – obatan selama
kehamilan : ......................................
 Imunisasi TT
: .......................................................................
 Prenatal care
: ..........................................................................
 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’
: .........................................................................
 Resusitasi
: ........................................................................ .....
 Pemberian O2
: ........................................................................
 Pernapasan
spontan/tidak : ...................................................................
 Frekuensi : ...........................................................
..............
 Teratur/tidak : .....................................................................
.......
 Menangis : ...........................................................
...............

5. RIWAYAT KESEHATAN KELUARGA


a. Genogram (3 generasi)
b. Kesehatan keluarga
..........................................................................................................
..........................................................................................................
..........................................................................................................
..........................................................................................................
................................................

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. Tatus gizi / pertumbuhan


 Berat badan
: ...................................................................................
 Panjang badan
: .................................................................................
 Lingkar lengan
: ....................................................................................
 Lingkar dada
: ......................................................................................
 Lingkar kepala
: ...................................................................................

d. Pemeriksaan cepalo caudal


1. Kepala dan rambut
 Ubun – ubun kecil
: .........................................................................
 Caput Succedenum
: ........................................................................
 Chepal hematoma
: .......................................................................
 Ukuran lingkar
kepala : ....................................................................
 Fronto occipito
: .........................................................................

2. Mata
 Bentuk/simetris : ......................................................................
.......
 Kotoran : ..............................................................................
.....
 Konjungtiva : .....................................................................
..............
 Sklera : ..............................................................................
.....
 Palpebra : ..............................................................................
....

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
...........................................................................................
...........................................................................................
...................
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 tangan
: ..........................................................................
 Reflek grasping
: .........................................................................
 Refleks moro
: ..........................................................................
 Refleks grasping
: .......................................................................
 Refleks menari
: .......................................................................
 Jari-jari tangan
: .........................................................................
 Akrosianosis : ...........................................................
...............

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
: ..................................................................................
 Tanda lahir
: ...................................................................................
 Kelainan : ..............................................................................
.....

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

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