(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 : ..................................................................
6. RIWAYAT IMUNISASI
..............................................................................................................
..............................................................................................................
..............................................................................................................
...................................
b. Pola eliminasi
BAK
Frekuensi/
jumlah : .............................................................................
Warna
: ..................................................................................
BAB
Frekuensi : ..............................................................................
...
Warna : ..............................................................................
.....
Konsistensi : ..............................................................................
....
8. PEMERIKSAAN FISIK
a. Keadaan umum
..........................................................................................................
..........................................................................................................
..........................................................................................................
................................
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
: .......................................................................
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 : ...........................................................
...............
12. Integumen
Warna kulit
: ..................................................................................
Tanda lahir
: ...................................................................................
Kelainan : ..............................................................................
.....
9. PEMERIKSAAN PENUNJANG
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
10. PENATALAKSANAAN
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
.........................
Banyuwangi,..........................
20…Mahasiswa
(………………………….)