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PENGKAJIAN
Tanggal MRS/Jam :
Tanggal Pengkajian/Jam :
Tempat :
A. DATA SUBYEKTIF
1. Identitas
Umur :...............................................................................................................................
Dx Medis :................................................................................................................................
2. Keluhan Utama
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3. Identitas Orang Tua
Ayah Ibu
Nama : :
Umur : :
Suku/Bangsa : :
Agama : :
Pendidikan : :
Pekerjaan : :
Alamat : :
4. Riwayat Prenatal
- Kehamilan ke :....................................................................................................................
- Imunisasi TT :.....................................................................................................................
4. Riwayat IntraNatal
- Persalinan ke :..........................................................................................................
1 Denyut Jantung
2 Usaha nafas
3 Tonus otot
4 Reflek
5 Warna kulit
TOTAL
2. Eliminasi
4. Personal hygiene
5. Aktivitas
7. Status Imunisasi :.......................................................................................................................................
B. DATA OBJEKTIF
1. Pemeriksaan Umum
b. kesadaran : ......................................................................................................................................
c. Tanda vital
Nadi :.......................................................................................................................................
Pernafasan :.....................................................................................................................................
Suhu :.......................................................................................................................................
2. Pemeriksaan Antropometri
BB :....................................................................................................................................................
PB :....................................................................................................................................................:
LK :....................................................................................................................................................
LD .....................................................................................................................................................:
LLA :....................................................................................................................................................
2. Pemeriksaan Fisik
Kepala : ...................................................................................................................................................
Muka :....................................................................................................................................................
Ubun-ubun :....................................................................................................................................................
Mata :....................................................................................................................................................
Hidung :....................................................................................................................................................
Telinga :....................................................................................................................................................
Mulut :....................................................................................................................................................
Leher :....................................................................................................................................................
Dada :....................................................................................................................................................
Tali pusat :....................................................................................................................................................
Abdomen :....................................................................................................................................................
Punggung :....................................................................................................................................................
Ekstermitas :....................................................................................................................................................
Genitalia :....................................................................................................................................................
Anus :....................................................................................................................................................
3. Pemeriksaan Neurologis
Moro :....................................................................................................................................................
Rooting :....................................................................................................................................................
Sucking :....................................................................................................................................................
Swallowing :....................................................................................................................................................
Walking :....................................................................................................................................................
Graphs :....................................................................................................................................................
Tonicneck :....................................................................................................................................................
Burning :....................................................................................................................................................
5. Pemeriksaan Penunjang
a. Pemeriksaan Laboratorium
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b. Terapi
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