ASUHAN KEPERAWATAN

KEGAWATDARURATAN BAYI
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Disusun Oleh :
NAMA : __________________
NIM : __________________

KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN KEMENKES MALANG
FORMAT PENGKAJIAN
JURUSAN KEPERAWATAN
PROGRAM STUDI SARJANA TERAPAN
KEPERAWATAN LAWANG
 A. PENGKAJIAN

A1. PENGUMPULAN DATA

I. BIODATA
IDENTITAS BAYI IDENTITAS BAPAK
Nama : __________________ Nama : __________________
No. Register : __________________ Umur : __________________
Umur : __________________ Jenis kelamin : __________________
Jenis kelamin : __________________ Alamat : __________________
Alamat : __________________ Pendidikan : __________________
Suku bangsa : __________________ Pekerjaan : __________________
Tanggal lahir/Umur : __________________ Suku bangsa : __________________
Tgl MRS : __________________ No. Tlp/HP : __________________
Tanggal pengkajian : __________________
Diagnosa medis : __________________ IDENTITAS IBU
Urutan anak : __________________
Nama : __________________
Umur : __________________
Jenis kelamin : __________________
Alamat : __________________
Pendidikan : __________________
Pekerjaan : __________________
Suku bangsa : __________________
No. Tlp/HP : __________________

II. DATA UMUM

a. Berat badan lahir : _________________gram Nadi : __________x/menit
b. Panjang badan lahir : _________________cm Suhu : __________oC
c. Berat badan saat ini : _________________gram RR : __________ x/menit
d. Panjang badan saat ini: _________________cm

III. KELUHAN UTAMA/ALASAN KUNJUNGAN

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IV. RIWAYAT KESEHATAN

A. RIWAYAT KEHAMILAN
1) Jumlah kunjungan ke bidan/dokter : __________________________________________
2) Pendidikan kesehatan yang didapatkan : ______________________________________
3) Kenaikan BB selama hamil : ________________________________________________
4) Penyakit yang diderita ibu saat hamil : ________________________________________
5) Pemeriksaan Lab/Radiologi saat hamil : _______________________________________
6) Keluhan saat hamil : ______________________________________________________
7) Imunisasi selama hamil : ___________________________________________________
8) Obat-obatan/vitamin yang dikonsumsi : ________________________________________
9) Riwayat minum jamu : _____________________________________________________
10)Riwayat dipijat (Bhs Jawa: dioyok) : __________________________________________
 B. RIWAYAT KELAHIRAN
1) Lama persalinan : ________________________________________________________
2) Komplikasi persalinan : ____________________________________________________
3) Tindakan pertolongan persalinan: ____________________________________________
4) Tempat melahirkan : ______________________________________________________
5) Penolong persalinan : _____________________________________________________
6) Usia gestasi : ____________________________________________________________
7) Kondisi air ketuban : ______________________________________________________

C. RIWAYAT POST NATAL

1) Pernafasan/usaha bernafas (denga/tanpa bantuan) : _____________________________
2) Tonus otot : _____________________________________________________________
3) Skor APGAR : ___________________________________________________________
4) Kebutuhan resusitasi (Jenis dan lamanya) : ____________________________________
5) Obat yang diberikan : _____________________________________________________
6) Trauma lahir : ___________________________________________________________

V. PEMERIKSAAN FISIK (HEAD TO TOE)

A. Keadaan Umum
Postur : ________________________________________________________________
Kesadaran: _____________________________________________________________
B. Kepala dan rambut
Kebersihan : ____________________________________________________________
Bentuk kepala : _________________________________________________________
Keadaan rambut : _______________________________________________________
Keadaan kulit kepala : caput succedanum, cefalohematom: _______________________
Fontanela anterior : lunak/menonjol/tegas/cekung/datar : _________________________
Sutura sagitalis : tepat/terpisah/menjauh : _____________________________________
Distribusi rambut : merata/tidak merata : ______________________________________
C. Mata
Kebersihan : ____________________________________________________________
Pandangan : ____________________________________________________________
Sclera : ________________________________________________________________
Conjungtiva : ___________________________________________________________
Pupil : _________________________________________________________________
Gerakan bola mata : _____________________________________________________
Pupil : _________________________________________________________________
Sekret : ________________________________________________________________
D. Hidung
Pernafasan Cuping hidung : ________________________________________________
Struktur : _______________________________________________________________
Kelainan lain : polip/perdarahan/peradangan : __________________________________
Sekresi : _______________________________________________________________
E. Telinga
Kebersihan : ___________________________________________________________
Sekresi : ______________________________________________________________
Struktur : ______________________________________________________________
Fistula aurikel : _________________________________________________________
F. Mulut dan Tengorokan
Jamur (stomatitis, moniliasis) : _____________________________________________
Kelaianan bibir dan rongga mulut (gnato/labio/palato skizis) : _____________________
Problem menelan : ______________________________________________________
G. Leher
Venajugularis : __________________________________________________________
Arteri karotis : __________________________________________________________
Pembesaran tiroid/limfe : __________________________________________________
 Torticoliis : _____________________________________________________________
H. Dada/Thorak (jantung dan Paru)
Bentuk dada : ___________________________________________________________
Pergerakan dinding dada : _________________________________________________
Tarikan dinding dada ke atas/bawah : ________________________________________
Suara pernafasan : _______________________________________________________
Frekwensi nafas : ________________________________________________________
Abnormalitas suara nafas : _________________________________________________
Suara jantung : __________________________________________________________
Kelainan jantung bawaan : _________________________________________________
I. Ekstremitas atas
Tonus otot : ____________________________________________________________
Trauma, deformitas : _____________________________________________________
Kelainan struktur : _______________________________________________________
J. Perut
Bentuk perut : ___________________________________________________________
Bising usus : ____________________________________________________________
Ascites, benjolan : _______________________________________________________
Turgor kulit : ____________________________________________________________
Vena : _________________________________________________________________
Hepar, lien : ____________________________________________________________
Distensi : ______________________________________________________________
K. Punggung
Spina bifida : ___________________________________________________________.
Deformitas : ____________________________________________________________
Kelainan struktur : _______________________________________________________
L. Genetalia dan anus
Kebersihan : ____________________________________________________________
Keadaan kelamin luar : ____________________________________________________
Anus : _________________________________________________________________
Kelainan : ______________________________________________________________
M. Ekstremitas bawah
Tonus otot : ____________________________________________________________
Trauma, deformitas : _____________________________________________________
Kelainan struktur : _______________________________________________________
N. Integumen
Warna kulit : ____________________________________________________________
Kelembaban : ___________________________________________________________
Lesi : __________________________________________________________________
Warna kuku, rambut : _____________________________________________________
Kelainan : ______________________________________________________________

VI. PENGUKURAN ANTROPOMETRI

Berat badan : ______________________________________________________________
Panjang badan : ____________________________________________________________
Lingkar kepala : ____________________________________________________________
Lingkar dada : _____________________________________________________________
Lingkar lengan Atas : ________________________________________________________

VII. REFLEKS PRIMITIF

Rooting : __________________________________________________________________
Menghisap : _______________________________________________________________
Menggenggam : ____________________________________________________________
Tonik Neck:__ _____________________________________________________________
Moro : ____________________________________________________________________
VIII. RIWAYAT IMUNISASI
Sebutkan imunisasi yang sudah diberikan beserta umur saat diimunisasi
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IX. PEMENUHAN KEBUTUHAN DASAR

A. OKSIGEN
Kebutuhan oksigen : _____________________________________________________
Dosis oksigen : _________________________________________________________
Cara pemberian : ________________________________________________________
B. CAIRAN:
Kebutuhan cairan dalam 24 jam : ___________________________________________
Jenis cairan yang diberikan : _______________________________________________
Cara/rute pemberian : ____________________________________________________
Balance cairan dalam 24 jam : _____________________________________________
Intake : ________________________________________________________________
Output : _______________________________________________________________
IWL : _________________________________________________________________
Kesimpulan : ___________________________________________________________
C. NUTRISI
Kebutuhan kalori : _______________________________________________________
Bentuk/jenis nutrisi yang diberikan : _________________________________________
Cara pemberian : ________________________________________________________
Frekwensi pemberian : ___________________________________________________
D. ELIMINASI URINE
Volume urine : __________________________________________________________
Warna : _______________________________________________________________
Frekwensi : ____________________________________________________________
Cara BAK (spontan/kateter) : ______________________________________________
Kelainan pemenuhan BAK : _______________________________________________
E. ELIMINASI ALVI
Volume feses : __________________________________________________________
Warna feses : __________________________________________________________
Frekwensi : ____________________________________________________________
Darah, lendir dalam feses : ________________________________________________
F. TIDUR
Jumlah jam tidur dalam 24 jam : ____________________________________________
Kualitas tidur (sering terbangun, rewel, tidak bisa tidur) : _________________________
G. PSIKOSOSIAL
Yang mengasuh : _______________________________________________________

X. TERAPI YANG DIPEROLEH PASIEN

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XI. DATA PENUNJANG
A. Radiologi
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan
B. Laboratorium
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan
C. Pemeriksaan khusus
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan
A. Pemeriksaan lainnya
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

Mengetahui, ______________,_________________
Pembimbing klinik
Mahasiswa

(______________________________) (______________________________)
NIM. __________________________
A2. ANALISIS DATA

HARI/TGL : ...............................................................................................

KEMUNGKINAN
NO DATA MASALAH
PENYEBAB
B. DIAGNOSA KEPERAWATAN

NAMA & TANDA

NO TANGGAL DIAGNOSA KEPERAWATAN
TANGAN PERAWAT
C. RENCANA TINDAKAN KEPERAWATAN

DIAGNOSA TUJUAN DAN KRITERIA NAMA & TANDA

NO INTERVENSI RASIONAL
KEPERAWATAN HASIL TANGAN PERAWAT
 DIAGNOSA TUJUAN DAN KRITERIA NAMA & TANDA
NO INTERVENSI RASIONAL
KEPERAWATAN HASIL TANGAN PERAWAT
D. IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN

NAMA & TANDA

NO TANGGAL JAM TINDAKAN KEPERAWATAN
TANGAN PERAWAT
A. EVALUASI
DIAGNOSA
NO
KEPERAWATAN
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TANGGAL
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Mengetahui,
Pembimbing Klinik
(_____________________________)
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Mahasiswa
( _____________________________ )
NIM. _________________________