UNIVERSITAS NAHDLATUL ULAMA SURABAYA

FAKULTAS KEPERAWATAN DAN KEBIDANAN

PROGRAM STUDI PROFESI NERS
KAMPUS A JL. SMEA NO. 57 SURABAYA (031) 8291920, 8284508, FAX (031) 8298582
KAMPUS B RS. ISLAM JEMURSARI JL. JEMURSARI NO. 51-57 SURABAYA
Website : www.unusa.ac.id Email : info@unusa.ac.id

ASUHAN KEPERAWATAN NEONATUS

Nama Mahasiswa : ______________ RS : ______________

NIM : ______________ Ruangan : ______________
Tanggal Pengkajian : ______________ Jam : ______________

A. IDENTITAS PASIEN
Nama : __________________________
Umur : __________________________
Tanggal Lahir : __________________________
Jenis Kelamin : __________________________
Berat Badan : __________________________
Panjang Badan : __________________________

B. IDENTITAS ORANG TUA

Nama Ibu : ______________ Nama Ayah : ______________
Umur : ______________ Umur : ______________
Agama : ______________ Agama : ______________
Pendidikan : ______________ Pendidikan : ______________
Pekerjaan : ______________ Pekerjaan : ______________
Alamat : __________________________________________

C. RIWAYAT KEHAMILAN DAN KELAHIRAN

1. Pranatal
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2. Intranatal
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

3. Pascanatal
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
D. KELUHAN UTAMA
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
E. RIWAYAT PENYAKIT SEKARANG
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

F. RIWAYAT PENYAKIT DAHULU

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

G. RIWAYAT PENYAKIT KELUARGA

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

H. PEMERIKSAAN FISIK
1. Tanda Vital
Suhu badan : ______________ °C
Nadi : ______________ kali/menit
Respirasi : ______________ kali/menit
2. Antropometri
Berat badan : ______________ kg
Panjang badan : ______________ cm
Lingkar kepala : ______________ cm
3. Pemeriksaan Kepala
a) Lingkar Kepala :
 Lingkar Sub Occipito Bregnatica : ______________ cm
 Lingkar Fronto Occipitalis : ______________ cm
 Lingkar Mento Occipitalis : ______________ cm
b) Kelainan kepala :
 Caput succedanum  Cephal hematom  Hidrocephalus
 Microcephalus  Anencephalus
c) Lain-lain :
_____________________________________________________________________
4. Pemeriksaan Mata
________________________________________________________________________
________________________________________________________________________

5. Pemeriksaan Telinga
________________________________________________________________________
________________________________________________________________________

6. Pemeriksaan Hidung
________________________________________________________________________
________________________________________________________________________
7. Pemeriksaan Mulut
 ________________________________________________________________________
________________________________________________________________________
8. Pemeriksaan Leher
________________________________________________________________________
________________________________________________________________________
9. Pemeriksaan Dada
________________________________________________________________________
________________________________________________________________________
10. Pemeriksaan Abdomen
________________________________________________________________________
________________________________________________________________________
11. Pemeriksaan Genitalia
________________________________________________________________________
________________________________________________________________________
12. Pemeriksaan Anus
________________________________________________________________________
________________________________________________________________________
13. Pemeriksaan Integumen
________________________________________________________________________
________________________________________________________________________
14. Pemeriksaan Ekstremitas Atas
________________________________________________________________________
________________________________________________________________________
15. Pemeriksaan Ekstremitas Bawah
________________________________________________________________________
________________________________________________________________________
I. IMUNISASI
________________________________________________________________________
________________________________________________________________________

J. PEMERIKSAAN REFLEKS BAYI

1. Refleks Sucking :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
2. Refleks Graps :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
3. Refleks Tonic Neck :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
4. Refleks Rooting :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
5. Refleks Moro :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
6. Refleks Babinski :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
7. Refleks Menelan :  Ada  Tidak ada
Jelaskan: ________________________________________________________________

K. PENILAIAN APGAR SCORE

 Tanda 0 1 2 1 menit 5 menit
Pucat/ Seluruh tubuh
Appearance Badan merah,
seluruhnya kemerah-
(warna kulit) ekstremitas biru
biru merahan
Pulse < 100 kali/
Tidak ada > 100 kali/ menit
(denyut nadi) menit
Meringis/ Meringis/ batuk/
Tidak ada
Grimace menangis lemah bersin saat
respon thdp
(refleks) ketika stimulasi saluran
stimulasi
distimulasi nafas
Activity Lemah/ Tidak
Sedikit gerakan Gerakan aktif
(tonus otot) ada
Menangis kuat,
Respiration Lemah/tidak
Tidak ada pernapasan baik
(pernapasan) teratur
dan teratur
Total skor

L. DATA TAMBAHAN
1. Laboratorium
________________________________________________________________________
________________________________________________________________________
2. Radiologi
________________________________________________________________________
________________________________________________________________________

3. Terapi Medis
________________________________________________________________________
________________________________________________________________________

4. Ballard Score
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
5. Down Score

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

6. Cremer Icterus

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________