ASUHAN KEPERAWATAN NEONATAL

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PENGKAJIAN

Tanggal MRS/Jam :

Tanggal Pengkajian/Jam :

Tempat :

A. DATA SUBYEKTIF

1. Identitas

Nama Bayi :...............................................................................................................................

Tanggal/Jam Lahir :...............................................................................................................................

Jenis Kelamin :................................................................................................................................

Umur :...............................................................................................................................

Dx Medis :................................................................................................................................

2. Keluhan Utama

a) Saat MRS :……………..............................................................................................................

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b) Saat Pengkajian :………………..........................................................................................................

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3. Identitas Orang Tua

Ayah Ibu

Nama : :

Umur : :

Suku/Bangsa : :

Agama : :

Pendidikan : :

Pekerjaan : :

Alamat : :

4. Riwayat Prenatal

- Kehamilan ke :....................................................................................................................

- Tempat ANC :....................................................................................................................

- Imunisasi TT :.....................................................................................................................

- Obat-Obatan yang pernah diminum selama hamil :..........................................................................

- Penerimaan Ibu/Keluarga Terhadap kehamilan :.........................................................................

- Masalah yang pernah dialami ibu saat hamil :...........................................................................

4. Riwayat IntraNatal

- Persalinan ke :..........................................................................................................

- Tempat dan penolong persalinan :..........................................................................................................

- Masalah saat persalinan :...........................................................................................................

- Jenis Persalinan :............................................................................................................

- Lama persalinan :.............................................................................................................

- Keadaan bayi saat lahir :.............................................................................................................

- Segera menangis/tidak :..............................................................................................................

5. Riwayat Natal

- Keadaan bayi baru lahir

- Lahir tanggal : .....................................,jam..........................................................

- Masa gestasi : ........................................ minggu

- BB/PB lahir :.........................gram, ......................cm

- Nilai APGAR : 1 menit/5menit/10 menit/2 jam:

No Kriteria 1 menit 5 menit 10 menit 2 jam

1 Denyut Jantung

2 Usaha nafas

3 Tonus otot

4 Reflek

5 Warna kulit

TOTAL

6. Pola Fungsi kesehatan

Kebutuhan Dasar Saat MRS Saat Pengkajian

1. Cairan & Makanan

2. Eliminasi

3. Istirahat & Tidur

4. Personal hygiene

5. Aktivitas

7. Status Imunisasi :.......................................................................................................................................

B. DATA OBJEKTIF

1. Pemeriksaan Umum
a. Keadaan 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 : ....................................................................................................................................................
PEMERIKSAAN PENUNJANG

1) Pemeriksaan Laboratorium
Jenis Pemeriksaan Hasil Satuan Nilai Rujukan
3) Pemeriksaan Radiologi

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4) Tindakan dan Terapi

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 ANALISA DATA

NAMA : .................................................. NO.RM : ...............

DX MEDIS : ..................................................
Data Penunjang Penyebab Masalah

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 DIAGNOSA KEPERAWATAN

NAMA : .................................................. NO.RM : ...............

DX MEDIS : ..................................................

No Tgl Diagnosa Keperawatan Tgl. Teratasi

Muncul
 RENCANA TINDAKAN KEPERAWATAN

NAMA : .................................................. NO.RM : ...............

DX MEDIS : ..................................................
No. Diagnosa Keperawatan SLKI SIKI
No. Diagnosa Keperawatan SLKI SIKI
No. Diagnosa Keperawatan SLKI SIKI
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN
NAMA : .................................................. NO.RM : ...............
DX MEDIS : ..................................................
No No. DX Implementasi Keperawatan Evaluasi
No No. DX Implementasi Keperawatan Evaluasi
No No. DX Implementasi Keperawatan Evaluasi