YAYASAN KARUNIA ABADI

SEKOLAH TINGGI ILMU KESEHATAN (STIKES)

INSAN UNGGUL SURABAYA
Kampus : Jl. Raya Kletek, No.4 Sidoarjo, Telp. (031) 7860630; Fax. (031) 7860630

FORMAT PENGKAJIAN
ASUHAN PADA PASIEN NEONATUS

Nama Fasilitator : Nama Mahasiswa :

Nilai : NIM :

Tanggal MRS : Jam :

No. Register : Tempat/ Tgl Pengkajian :

1. PENGKAJIAN
1.1. ANAMNESE
1.1.1. BIODATA
1. Identitas Pasien (Neonatus)
a. Nama : .........................................................................................
b. Jenis Kelamin :L/P
c. Tempat/ Tgl Lahir : .........................................................................................
d. Umur : .........................................................................................
2. Penanggung Jawab Klien/ Orang Tua
a. Nama Pasien : ................................. a. Nama Suami : ..................................
b. Umur : ................................. b. Umur : ..................................
c. Suku/ Bangsa : ................................. c. Suku/ Bangsa : ..................................
d. Agama : ................................. d. Agama : ..................................
e. Pendidikan : ................................. e. Pendidikan : ..................................
f. Pekerjaan : ................................. f. Pekerjaan : ..................................
g. Alamat : ................................. g. Alamat : ..................................
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1.1.2. Keluhan Utama
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1.1.3. Riwayat Kesehatan Sekarang
(Diuraikan dari timbulnya gejala penyakit sampai sekarang)
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1.1.4. Riwayat Kesehatan Sebelum Sakit Ini :
a. Riwayat Prenatal :
1) HPHT : ..............................................................................................
2) Imunisasi TT :( ) Ya ( ) Tidak, Sebanyak ................................... X
3) BB : ..............................................................................................
4) ANC :( ) Ya ( ) Tidak, Sebanyak ................................... X
5) Keluhan TM I, II, III : ..............................................................................................
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b. Riwayat Intranatal :
1) Usia Kehamilan : ..............................................................................................
2) Tempat Lahir : ..............................................................................................
3) Lama Persalinan : ..............................................................................................
4) Penolong : ..............................................................................................
5) Penyulit : ..............................................................................................
6) Jenis Persalinan : ..............................................................................................
7) Penggunaan Obat Selama Kehamilan : .....................................................................
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c. Riwayat Postnatal :
1) Usaha Nafas :( ) Dengan Bantuan ( ) Tanpa Bantuan
2) APGAR Score : ..............................................................................................
3) BB Lahir : ..............................................................................................
4) BB Saat MRS : ..............................................................................................
5) Riwayat Alergi : ..............................................................................................
6) Kebutuhan Resusitasi ( Jenis dan Lama) : ................................................................
7) Trauma Lahir : ..............................................................................................
8) Riwayat Imunisasi : ..............................................................................................
9) Riwayat Sakit Sebelumnya : .....................................................................................
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1.1.5. Riwayat Kesehatan Keluarga
1) Penyakit Jantung 3) HT 5) DM 7) Abortus
2) Penyakit Ginjal 4) Penyakit Hati 6) Penyakit Kelamin\
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1.1.6. Kebutuhan Dasar Khusus
1. Pola Nutrisi
a. ASI Eksklusif : ..............................................................................................
b. Susu Formula : ..............................................................................................
c. Pemberian MT : ..............................................................................................
2. Pola Eliminasi : ..............................................................................................
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3. Personal Hygiene : ..............................................................................................
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4. Istrahat Tidur : ..............................................................................................
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5. Kebiasaan Lainnya : ..............................................................................................
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1.2. PEMERIKSAAN FISIK
1. Reflex
a. Refleks Moro : ..............................................................................................
b. Refleks Menggenggam : ..............................................................................................
c. Refleks Menghisap : ..............................................................................................
d. Refleks Mencari : ..............................................................................................
e. Refleks Babinsky : ..............................................................................................
f. Tonus Otot : ..............................................................................................
2. Tanda Vital :
a. Keadaaan Umum : ..............................................................................................
b. GCS : ..............................................................................................
c. RR : ..............................................................................................
d. Nadi : ..............................................................................................
e. CRT : ..............................................................................................
f. Suhu : ..............................................................................................

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 3. Antropometri :
a. BB : ..............................................................................................
b. PB : ..............................................................................................
c. Lingkar Kepala :
1) C. Fronto Occipitalis : ....................................................................
2) C. Sub Occipitalis Bregmatika : ....................................................................
3) C. Mento Occipitalis : ....................................................................
d. Lingkar Lengan : ..............................................................................................
e. Lingkar Dada : ..............................................................................................
4. Pemeriksaan Umum :
1) Pernafasan
a. Spontan / Tidak : ..............................................................................................
b. RR : ..............................................................................................
c. Apgar Score : ..............................................................................................
d. Pemberian O2 : ..............................................................................................
e. Sianosis : ..............................................................................................
f. Suara Nafas : ..............................................................................................
2) Sirkulasi :
a. Nadi : ..............................................................................................
b. CRT : ..............................................................................................
c. Ekstremitas : ..............................................................................................
d. Perdarahan : ..............................................................................................
3) Nutrisi, Cairan dan Elektrolit
a. Diet : ..............................................................................................
b. BB Lahir, BB MRS, BB Saat ini : ...........................................................................
c. Pemberian Minum : ..............................................................................................
d. Muntah : ..............................................................................................
e. Masalah Kesehatan Mulut : .....................................................................................
f. Monialiasis : ..............................................................................................
g. Abdomen : ..............................................................................................
h. Lidah : ..............................................................................................
i. Mukosa : ..............................................................................................
j. Turgor : ..............................................................................................
4) Genetalia :
a. Keadaan Kelamin : ..............................................................................................
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b. Sekret : ..............................................................................................

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 5) Eliminasi :
a. BAK : ..............................................................................................
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b. BAB : ..............................................................................................
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6) Neurosensori :
a. Respon Nyeri : ..............................................................................................
b. Tangisan : ..............................................................................................
c. Lingkar Kepala : ..............................................................................................
d. Trauma Lahir : ..............................................................................................
e. Kelainan Kepala : ..............................................................................................
f. Ubun – ubun : ..............................................................................................
g. Pupil : ..............................................................................................
h. Gerakan : ..............................................................................................
i. Kejang : ..............................................................................................
7) Intergumen :
a. Warna Kulit : ..............................................................................................
b. Akral : ..............................................................................................
c. Turgor : ..............................................................................................
d. Integritas : ..............................................................................................
e. Kebersian Kepala dan Rambut : ..............................................................................
f. Mata : ..............................................................................................
g. Tali Pusat : ..............................................................................................
8) Rasa Nyaman :
a. Respon Tangisan : ..............................................................................................
9) Tidur dan Istirahat : ..............................................................................................
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10) Psikososial :
a. Persepsi orang tua terhadap kesehatan bayi saat ini
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b. Harapan terhadap perawatan bayi
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 11) Sosial Ekonomi
a. Biaya Perawatan : ..............................................................................................
b. Status Anak : ..............................................................................................
c. Perhatian Orang tua : ..............................................................................................
1.3. PEMERIKSAAN LABORATORIUM
1. Darah :
a. Hb : ..............................................................................................
b. Golongan : ..............................................................................................
2. Urine :
a. Albumin : ..............................................................................................
b. Reduksi : ..............................................................................................
1.4. PEMERIKSAAN LAINNYA
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1.5. TERAPI
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1.6. DATA TAMBAHAN
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Mengetahui ......................, Tgl……………………..

CI / Ka. Ruangan Pemeriksa

(………………………………………….) (………………………………………….)

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 ANALISA DATA
No. Tgl/ Jam Data Penyebab Masalah

Diagnosa Keperawatan
1. ..............................................................................................................................................
..............................................................................................................................................
2. ..............................................................................................................................................
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3. ..............................................................................................................................................
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 RENCANA KEPERAWATAN
Nama / Inisial Pasien : …………………………
No RM : …………………………
Diagnosa Medis : …………………………
No Diagnosa Tujuan Intervensi Rasional

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 IMPLEMENTASI KEPERAWATAN
Nama / Inisial Pasien : …………………………
No RM : …………………………
Diagnosa Medis : …………………………
No Diagnosa Tgl/ Jam Implementasi Tgl/ Jam Evaluasi

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 CATATAN PERKEMBANGAN

No. Hari/ Tgl Diagnosa Catatan Perkembangan (SOAPI)

Mengetahui ………………., Tgl ………………………

CI/ Ka. Ruangan Penyusun

( ………………………………………….) ( ………………………………………….)

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