PENGKAJIAN FISIK BAYI BARU LAHIR

Nama Bayi : ………………… Tanggal/Waktu Lahir ………………… P/L

Nama Ibu/Umur : ………………… Pekerjaan …………………………………..

CATATAN DARI RUANG INTRA NATAL

(Riwayat kelahiran, nilai Apgar)
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PENGKAJIAN AWAL
KEADAAN UMUM BAYI
(warna kulit, tonus otot, postur, BB dan PB, respons bayi terhadap rangsangan interna dan
eksterna)
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VITAL SIGN
Nadi : ....................................................................................................................................
RR : ....................................................................................................................................
Suhu : ....................................................................................................................................

USAHA BERNAFAS (retraksi, gasping, grunting, dan kualitas tangisan)

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KEADAAN UMUM TUBUH

Kulit Tubuh (lanugo, verniks, tekstur, turgor, hidrasi, rash, dan pigmentasi)
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Posterior tubuh (palpasi simetrikal, keutuhan dan massa tulang belakang; patensi anus;
keutuhan lekukan pilonidal)
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KEPALA DAN LEHER

Kepala (simetrikal, ada-tidaknya molding, caput succedaneum dan cephalohematoma, ada
tidaknya abrasi)
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Fontanel dan Suture (ada-tidaknya tonjolan, cekungan, overriding)
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Lingkar Kepala (ukuran suboccipito bregmantika, occipito frontalis)
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Telinga (posisi & bentuk)
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Wajah (simetrikal saat diam dan menangis, abrasi, kontusi)
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Mata (bentuk, posisi, keadaan pupil, ada-tidaknya perdarahan, sekret, refleks cahaya)
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Mulut (keadaan membran mukosa, lidah, mukus/saliva, ada tidaknya labioskizis,
palatolabioskizis dan gigi)
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Leher (mobilitas, ada-tidaknya kantung lemak, abrasi, dan kontusi)
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Hidung (simetrikal, septum, mucus/secret, pernafasan cuping, milia)
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EKSTREMITAS
Ekstremitas Atas (simetrikal, posisi dan kemampuan gerak, jumlah jari dan abnormalitas,
nadi radialis)
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Ekstremitas Bawah (simetrikal, posisi dan kemampuan gerak, jumlah jari dan abnormalitas, nadi
femoral)
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THORAKS
Keadaan Umum (keutuhan klavikula dan ada-tidaknya massa, bentuk, ukuran, dan simetrikal)
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Jantung dan Paru (bunyi nafas dan jantung; irama, frekuensi, denyut apical)
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ABDOMEN
Keadaan Umum (bentuk dan ukuran, peristaltik, distensi )
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Hati dan Ginjal (palpasi)
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Keadaan Tali Pusat ( ) Normal ( ) Tidak, Jelaskan!
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Perawatan tali pusat; Jelaskan!
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GENITOUNINARI
Bayi Perempuan (observasi yang terlihat dan kesesuaiannya, maturasi labia dan sekresi
vagina)
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Bayi laki-laki (observasi yang terlihat dan kesuaiannya, posisi lubang uretra, maturasi
skrotum, ada-tidaknya testes)
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Eliminasi (ada-tidaknya urine dan fekal dalam 24 jam, warna dan jumlahnya; tipe fekal)
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FUNGSI NEUROLOGIK DAN REFLEKS (deskripsikan cara mengkaji dan hasilnya)

Rooting dan Menghisap …..
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Menggenggam (palmar dan plantar)
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Tonik Leher
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Moro
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Melangkah
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Babinsky
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NUTRISI (Asi/Pasi, jumlah dan waktu pemberian)

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MEDIKASI DAN TERAPI

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PEMERIKSAAN PENUNJANG
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KEMAMPUAN IBU BERHUBUNGAN DENGAN PERAWATAN BBL
(Keluhan, pertanyaan dan pernyataan ibu berhubungan dengan perawatan BBL)
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PENGKAJIAN LANJUTAN BBL

Item Waktu Keterangan

K/U
RR
-Frekuensi:
-Regular (√)
-Irregular (-)
-Pernafasan
cuping
hidung (+/-)
-Suara nafas
-Apnea
Nadi
Apical:
Perifer:
Suhu aksila
Mukosa mulut
Kulit
-Joundice (+/-)
-petechiae (+/-)
BAB
-frekuensi:
-jumlah:
-konsistensi:
-warna:
BAK
-frekuensi:
-warna:
Abdomen
-distensi (+/-)
-peristaltik (+/-)
-turgor
Tali pusat;
-merah (+/-)
-berbau (+/-)
-basah (+/-)
-berdarah(+/-)
Intake Nutrisi
ASI/PASI
Jumlah;
(Asi : menetes/
mengalir/
memancar)
PASI : .....cc)
BB = ........gram
Aktivitas
Kualitas tangisan;
-kuat/lemah/melengking
-suara parau (+ / -)

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