PROGRAM STUDI PROFESI NERS

STIKES GUNA BANGSA YOGYAKARTA

SK MENDIKNAS RI No. 70/D/O/2009
Jl. Ringroad Utara Condong Catur Depok Sleman Yogyakarta Telp. (0274) 4477701, 4477703, 4477704 Fax. (0274)
4477702

PENGKAJIAN NEONATUS

DATA BAYI
Nama Bayi : BB / PB :
Jenis Kelamin : Apgar Score :
Tanggal lahir / Usia :

DATA ORANG TUA

IBU AYAH
Nama
Pekerjaan
Pendidikan
Alamat

PENGKAJIAN FISIK NEONATUS

Beri tanda chek pada istilah yang tepat / sesuai dengan data – data di bawah ini. Gambarkan
sebuah temuan abnormal secara objektif, gunakan kolom data tambahan bila perlu.

1. Reflek
Palmar GRASP / mengenggam (sejak lahir s/d 6 bulan) [ ]
Cara: Memberikan stimulus penekanan atau penempatan jari pemeriksa pada
telapak tangan bayi
Respons: bayi akan mengepal dan memegang atau menggenggam jari pemeriksa
Plantar GRASP / mengenggam (sejak lahir s/d 9-10 bulan) [ ]
Cara: Memberikan stimulus penekanan atau penempatan jari pemeriksa pada
tumit kaki bayi
Respons : Normalnya jari kaki bayi akan menutup
Menghisap [ ]

Snout (sejak lahir s/d 3 bulan) [ ]

Tonic Neck (sejak lahir s/d 5-6 bulan) [ ]
Placing Response [ ]
Ket
.............................................................................................................................................

2. Pemeriksaan Antropometri
BB :
TB / PB :
Lingkat Kepala:
Lingkar lengan Atas :
Status Gizi :
 PROGRAM STUDI PROFESI NERS
STIKES GUNA BANGSA YOGYAKARTA
SK MENDIKNAS RI No. 70/D/O/2009
Jl. Ringroad Utara Condong Catur Depok Sleman Yogyakarta Telp. (0274) 4477701, 4477703, 4477704 Fax. (0274)
4477702

3. Tonus / aktifitas
a. Aktif [ ] Letargi [ ] Kejang [ ]
b. Menangis keras [ ] Lemah [ ] Melengking [ ] Sulit menangis [ ]
Ket.......................................................................................................................................

4. Kepala / leher
a. Fontanel anterior : Lunak [ ] Tegas [ ] Datar [ ] Menonjol [ ]
Cekung [ ]
b. Sutura Sagitalis : Tepat [ ] Terpisah [ ] Menjauh [ ]
c. Gambaran Wajah : Simetris [ ] Asimetris [ ]
d. Molding : Caput Succedanium [ ] Cephalohematoma [ ]
Ket.......................................................................................................................................

5. Mata
Bersih [ ] Sekresi [ ]
Ket.......................................................................................................................................

6. THT
Telinga : Normal [ ] Abnormal [ ]
Hidung : Normal [ ] Abnormal [ ]
Ket.......................................................................................................................................

7. Abdomen
a. Lunak [ ] Tegas [ ] Kembung [ ]
b. Lingkar perut : .............. cm
c. Liver : Kurang 2 cm [ ] Lebih 2 cm [ ]
Ket...................................................................................................................................

8. Thoraks
a. Simetris [ ] Asimetris [ ]
b. Retraksi : Derajad 1 [ ] Derajad 2 [ ] Derajad 3 [ ]
c. Klavikula : Normal [ ] Abnormal [ ]
Ket.......................................................................................................................................

9. Paru – paru
a. Suara nafas kanan dan kiri : Sama [ ] Asimetris [ ]
 PROGRAM STUDI PROFESI NERS
STIKES GUNA BANGSA YOGYAKARTA
SK MENDIKNAS RI No. 70/D/O/2009
Jl. Ringroad Utara Condong Catur Depok Sleman Yogyakarta Telp. (0274) 4477701, 4477703, 4477704 Fax. (0274)
4477702

b. Bunyi nafas di semua lapang paru : Terdengar [ ] Tidak terdengar [ ]

Menurun [ ]
c. Suara nafas : Bersih [ ] Ronchi [ ] Rales [ ]
Sekresi [ ]
d. Respirasi : Spontan [ ] Alat bantu [ ]
Keterangan:.............................................................................................................

10. Jantung
a. Bunyi: Normal Sinys rhythm (NSR) [ ] Frekuensi : ..........................
b. Waktu Pengisian kapiler : ...................................
Ket.......................................................................................................................................

11. Ekstremitas
a. Gerakan bebas [ ] ROM terbatas [ ] tidak terkaji [ ]
b.
Nadi Perifer Keras Lemah Tidak Teraba
Brakial kanan
Brakial kiri
Femoral kanan
Femoral kiri

c. Ekstremitas atas : normal [ ] abnormal [ ] : .....................................................

d. Ekstremitas bawah : normal [ ] abnormal [ ] : .........................Tidak terkaji [ ]
Ket.......................................................................................................................................

12. Umbiikus
Normal [ ] abnormal [ ] Inflamasi [ ] drainase [ ]
Ket.......................................................................................................................................

13. Genital
Perempuan normal [ ] Laki – laki normal [ ] Abnormal [ ]
Ket.......................................................................................................................................

14. Anus : Paten [ ] Imperforata [ ]

Ket.......................................................................................................................................

15. Spinal : Normal [ ] Abnormal [ ]

 PROGRAM STUDI PROFESI NERS
STIKES GUNA BANGSA YOGYAKARTA
SK MENDIKNAS RI No. 70/D/O/2009
Jl. Ringroad Utara Condong Catur Depok Sleman Yogyakarta Telp. (0274) 4477701, 4477703, 4477704 Fax. (0274)
4477702

Ket.......................................................................................................................................

16. Kulit
a. Warna : Pink [ ] Pucat [ ] Jaudine [ ] Sianosis pada kuku [ ]
sirkumoral [ ] periorbital [ ] seluruh tubuh [ ]
b. Kemerahan (rash) [ ]
c. Tanda lahir : ............................................................
Ket.......................................................................................................................................

17. Suhu
a. Lingkungan : Penghangat radian [ ] Pengaturan suhu [ ] incubator [ ] Suhu
ruangan [ ] Boks terbuka [ ]
b. Suhu kulit : .............................................
Ket.......................................................................................................................................

RIWAYAT PRENATAL (ANC)

1. Jumlah Kunjungan : ...............................................................................................
2. Bidan / dokter :...............................................................................................
3. Pendidikan Kesehatan yang didapat :.................................................................................
4. HPHT : ...............................................................................................
5. Kenaikan BB selama hamil: ...............................................................................................
6. Komplikasi kehamilan : ...............................................................................................
7. Komplikasi obat : ...............................................................................................
8. Obat – obatan yang didapat: ...............................................................................................
9. Pengobatan yang didapat : ................................................................................................
10. Riwayat hospitalisasi : ...............................................................................................
11. Golongan darah ibu hamil: ...............................................................................................
12. Kehamilan direncanakan / tidak : .....................................................................................

PEMERIKSAAN KEHAMILAN (MATERNAL SCREENING)

Rubella [ ] Hepatitis [ ] Clamidia [ ] VDRL [ ] GO [ ] Herpes [ ] HIV [ ]

RIWAYAT PERSALINAN (INTRANATAL)

1. Awal persalinan : ....................................................................................................
2. Lama persalinan : ....................................................................................................
3. Komplikasi persalinan: .............................................................................................
4. Terapi yang diberikan: ...............................................................................................
a. Jenis & jumlah: ...................................................................................................
b. Lama pemberian: ...................................................................................................
5. Lama antara Rupture vagina dan saat partus:..................................................................
6. Jumlah cairan ketuban: ...................................................................................................
7. Anastesi yang diberikan: ...................................................................................................
 PROGRAM STUDI PROFESI NERS
STIKES GUNA BANGSA YOGYAKARTA
SK MENDIKNAS RI No. 70/D/O/2009
Jl. Ringroad Utara Condong Catur Depok Sleman Yogyakarta Telp. (0274) 4477701, 4477703, 4477704 Fax. (0274)
4477702

8. Mekonium ada / tidak: ...................................................................................................

RIWAYAT KELAHIRAN
1. Indikasi dilakukan monitoring: ........................................................................................
2. Pola FHR (Fetal Heart Rate): ...........................................................................................
3. Analisa Gas Darah: ....................................................................................................
4. Lama Kala II : ....................................................................................................
5. Cara Melahirkan :Pervaginam [ ] Bantuan forceps/vacum ekstrasi [ ]Cesar [ ]
6. Tempat Melahirkan: ....................................................................................................
7. Presentasi : ....................................................................................................

RIWAYAT POST NATAL

1. Usaha nafas : Dengan bantuan [ ] tanpa bantuan [ ]
2. APGAR Score : Menit 1 ............................. Menit ke-5 .....................................
3. Kebutuhan Resusitasi : Jenis : .....................................................................................
Lama : ......................................................................................
4. Ada trauma lahir :[ ]
5. Adanya narcosis :[ ]
6. Keluarnya urine : [ ] BAB [ ]
7. Respon fisiologis atau perilaku bermakna :[ ]
8. Prosedur yang dilakukan:
A. Aspirasi gaster :[ ]
B. Suction trachea :[ ]

RIWAYAT SOSIAL
1. Struktur Keluarga (genogram)
 PROGRAM STUDI PROFESI NERS
STIKES GUNA BANGSA YOGYAKARTA
SK MENDIKNAS RI No. 70/D/O/2009
Jl. Ringroad Utara Condong Catur Depok Sleman Yogyakarta Telp. (0274) 4477701, 4477703, 4477704 Fax. (0274)
4477702

2. Antisipasi VS pengalaman nyata kelahiran

3. Budaya
Suku : .........................................................................................................................
Agama : .........................................................................................................................
Bahasa utama: ....................................................................................................................

4. Perencanaan makanan bayi

5. Problem sosial yang penting

System pendukung social :[ ]
Perbedaan bahasa :[ ]
Riwayat penyalahgunaan zat adikif :[ ]
Lingkungan rumah kurang memadai :[ ]
Keuangan :[ ]
Lain – lain : .....................................................................
6. Hubungan orang tua & bayi
Tingkah laku Ibu Ayah
Menyentuh
Memeluk
Berbicara
Berkunjung
Memanggil nama
Kontak mata

7. Orang tua berespon terhadap penyakit : Ya [ ] Tidak [ ]

Respon : .........................................................................

8. Orang tua berespon terhadap hospitalisasi : Ya [ ] Tidak [ ]

Respon : .............................................................
 PROGRAM STUDI PROFESI NERS
STIKES GUNA BANGSA YOGYAKARTA
SK MENDIKNAS RI No. 70/D/O/2009
Jl. Ringroad Utara Condong Catur Depok Sleman Yogyakarta Telp. (0274) 4477701, 4477703, 4477704 Fax. (0274)
4477702

9. Anak Lain
Jenis Kelamin Umur Riwayat Persalinan Riwayat Imunisasi
Anak
 PROGRAM STUDI PROFESI NERS
STIKES GUNA BANGSA YOGYAKARTA
SK MENDIKNAS RI No. 70/D/O/2009
Jl. Ringroad Utara Condong Catur Depok Sleman Yogyakarta Telp. (0274) 4477701, 4477703, 4477704 Fax. (0274)
4477702

PEMERIKSAAN PENUNJANG
Nama : No.RM: jenis Kelamin: Tanggal lahir:
1. Laboratorium
Tanggal Jenis Pemeriksaan Nilai normal Keterangan
 PROGRAM STUDI PROFESI NERS
STIKES GUNA BANGSA YOGYAKARTA
SK MENDIKNAS RI No. 70/D/O/2009
Jl. Ringroad Utara Condong Catur Depok Sleman Yogyakarta Telp. (0274) 4477701, 4477703, 4477704 Fax. (0274)
4477702

2. Usg/Thorax/Dll
Hari/tanggal/jam Jenis pemeriksaan Kesan