FORMAT PENGKAJIAN KEPERAWATAN NEONATUS

(Isi atau hitamkan kotak yang sesuai dengan data pada klien)

Hari / Tgl Pengkajian : ................................................................................................................

Identitas Pengkaji : ................................................................................................................

A. Data Demografi
1. Klien/ Pasien
a. Nama : ………………………………………........................................
b. Tgl lahir/usia : ………………………………………........................................
c. Jenis kelamin : ………………………………………........................................
d. Kewarganegaraan : ………………………………………........................................
e. Tanggal masuk RS : ………………………………………........................................
f. Diagnosa medis : ………………………………………........................................
2. Orang Tua/ Penanggung Jawab
a. Nama : ………………………………………........................................
b. Hubungan dengan klien : ………………………………………........................................
c. Alamat : ………………………………………........................................
d. No. Telepon : ………………………………………........................................

B. Riwayat Klien
1. Riwayat Kehamilan

-obatan : ………………………………………............................
-lain : ………………………………………....................................................................
2. Riwayat persalinan
Usia gestasi : ................................................................................................................
Berat badan lahir : ................................................................................................................
Jenis Persalinan : ................................................................................................................
Indikasi : ................................................................................................................
Apgar score : ................................................................................................................
Kejadian penting selama proses persalinan:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
 3. Faktor risiko ibu:

-lain : ………………………………………....................................................................
4. Riwayat alergi :

………………………………………......................................................…….

C. Riwayat Kesehatan Keluarga

1. Riwayat penyakit dalam keluarga:
…………………………………..................................................................................................
.………………………………….................................................................................................
2. Genogram

Keterangan gambar :
: laki-laki
: perempuan
: klien
: meninggal
: tinggal dalam satu rumah

D. Riwayat Penyakit Sekarang

1. Penampilan umum
a. Keadaan umum (kondisi klien secara umum):
…………………………………........................................................…….……………...…
………………………………........................................................……….………………...
 b. Pemeriksaaan Tanda-Tanda Vital
1) Pernapasan : ................... X/mnt
2) Suhu : ................... °C
3) Nadi : ................... X/mnt
4) Tekanan Darah :................... mmHg
5) Saturasi oksigen : ..............................
2. Oksigenasi :
a.
b.
c. Penggunaan alat bantu napas:

oksigen

: ………………………………………................................................................
d. Penggunaan otot bantu napas

e. idak ada
3. Nutrisi:
a. Berat badan : ................... kg
b. Lingkar lengan atas : ................... cm
c. Panjang badan : ................... cm
d. Lingkar kepala : ................... cm
e. Lingkar dada : ................... cm
f. Kebutuhan kalori : .............................
g. Jenis nutrisi:
……………………………………….................................................................
: ………………………………………............................................................
h. idak
i. Residu OGT : ..............cc, warna .................
4. Cairan
a. Kebutuhan cairan : ………………………………………....................................................
b.
……………………………………….................................................
c. Turgor kulit uruk
d. embab
 e. Ubun- ormal
f. ormal
g. Kapilary refill : ………………………………………..........................................................
h. Balance cairan : .................................................………………………………………........
5. Istirahat tidur
a. Status tidur-terjaga: ….........................................................…..............................................
b. urang baik, jelaskan ………….. .................................................
6. Aktivitas:
a. Gerakan
b. Tangisan emah
c. Sistem Muskuloskeletal
1) Postur kstensi
2) Tonus otot
...................................................……...

E. Pemeriksaan Head to toe

1. Integumen
Suhu :
Warna kulit
Integritas kulit:

kasi ………………………………………............................................................
2. Kepala dan leher
a.
Kelainan : .………………………………………....................
Belum menutup

nnya, sebutkan ………………………………….….....

b.
Lainnya, sebutkan …..…………………………..........
c. Kelopak mata (bentuk & gerak)
Bentuk ……...………………………...........
Gerak
dak simetris, sebutkan ……………………………………………….....
 d.
e.
f. Pupil

g. Telinga

r
h. Hidung

i. Leher

Tidak normal, sebutkan …………………………….........................................

3. Dada, paru-paru dan jantung
 Pengembangan dada:

kondisi …………………………….........................................................
 Ictus cordis ............

..........


4. Abdomen

…………………………….........................................
 Bising usus : ……… X/menit


Lainnya, sebutkan …………………………….............................................

 a, sebutkan............................……………………………............


……………………………...........……............................
 ……………………………................
 ............................................................
  Buang air besar

econium
...……………………………...........……..…..
5. Alat kelamin
Kelainan ...……………………………………….........
Kebersihan
Iritasi idak
6. Ekstremitas:
a. idak simetris
b. ormal
c. ingin
d. idak
7. Perkembangan (Refleks):

enelan

F. Pengkajian Psikososial
1. Res ewel
2. Pengetahuan orang tua tentang kondisi bayi:
.....................................................................................................................................................
...... ..............................................................................................................................................
3. Kunjungan orang tua terhadap bayi

h
4. Interaksi orang tua dan bayi

5. Suasana hati orang tua:

G. Data Penunjang:
1. Pemeriksaan penunjang:
......................................................................................................................................................
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......................................................................................................................................................
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2. Pengobatan
......................................................................................................................................................
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Pengkaji

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