FORMAT PENGKAJIAN

FORMAT PENGKAJIAN
(Perinatologi)
(Perinatologi)

A.
A. PENGKAJIAN
PENGKAJIAN
1.1. BIODATA
BIODATA
a.a. NamaBayi
Nama Bayi :: ..................................................................
..................................................................
b.b. Umur/Tanggallahir
Umur/Tanggal lahir :: ..................................................................
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c.c. JenisKelamin
Jenis Kelamin :: ..................................................................
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d.d. NomorRegister
Nomor Register :: ..................................................................
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e.e. TanggalMRS
Tanggal MRS :: ..................................................................
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f.f. TanggalPengkajian
Tanggal Pengkajian :: ..................................................................
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g.g. Diagnosmedis
Diagnos medis :: ..................................................................
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PENAGGUNGJAWAB
PENAGGUNG JAWAB
a.a. NamaBayi
Nama Bayi :: ..................................................................
..................................................................
b.b. Umur/Tanggallahir
Umur/Tanggal lahir :: ..................................................................
..................................................................
c.c. JenisKelamin
Jenis Kelamin :: ..................................................................
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d.d. Agama
Agama :: ..................................................................
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e.e. Pekerjaan
Pekerjaan :: ..................................................................
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f.f. Pendidikanterakhir
Pendidikan terakhir :: ..................................................................
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g.g. Statusperkawinan
Status perkawinan :: ..................................................................
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h.h. Sukubangsa
Suku bangsa :: ..................................................................
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2.2. KELUHANUTAMA
KELUHAN UTAMA // ALASAN
ALASAN MASUK
MASUK RUMAH
RUMAH SAKIT
SAKIT
a.a. Keluhansaat
Keluhan saatMRS
MRS
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b.b. Keluhansaat
Keluhan saatpengkajian
pengkajian
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3.3. RIWAYATPENYAKIT
RIWAYAT PENYAKIT SEKARANG
SEKARANG
a.a. Kronologispenyakit
Kronologis penyakit pasien
pasien (dirumah,
(dirumah, UGD/poli)
UGD/poli)

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Health Sciences
Sciences Banyuwangi
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4. RIWAYAT PENYAKIT MASA LALU

a. Antenatal (riwayat kehamilan)
● Status GPA : G...P...A...
● Usia kehamilan : ...............Minggui
● Perawatan antenatal (ANC) : Teratur Tidak teratur
● Tempat pemeriksaan ANC : ………………………………………………
● Penggunaan obat – obatan selama kehamilan : .......................................
● Imunisasi TT : .........................................................................
● Komplikasi penyakit selama kehamilan : ................................................

b. Natal (riwayat persalinan sekarang)

● Penolong persalinan : .............................................................................
● Tempat persalinan : .............................................................................
● Jenis persalinan : .............................................................................
● Air ketuban : ..........................................................................
● Lama persalinan kala II : ........................................................................
● Keadaan tali pusat : ..........................................................................

c. Post natal (neonatus)

● APGAR 1menit pertama dan 5 menit berikutnya : ..................................
● Usia gestasi : ……………………………… minggu (Ballard score)
● Resusitasi : ........................................................................ .....
● Pemberian O2 : .........................................................................
● Barat badan lahir : ……… gram; Panjang badan lahir ……. cm

5. RIWAYAT KESEHATAN KELUARGA

a. Genogram (3 generasi)

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b. Kesehatan keluarga
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c. Riwayat psikososial orang tua

1. Pengasuh : Ayah Ibu Nenek Orang lain
2. Dukungan sibling : Ada Tidak ada
3. Keterlibatan orang tua
● Berkunjung : Ya Tidak
● Kontak mata : Ya Tidak
● Menyentuh : Ya Tidak
● PMK : Ya Tidak
● Berbicara : Ya Tidak
● Menggendong : Ya Tidak

6. RIWAYAT IMUNISASI
................................................................................................................................................................
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.................................................
7. POLA KEBIASAAN SEHARI-HARI
a. Pola nutrisi
● Jenis makanan/minuman : ...................................................................
● Frekuensi : ........................................................................................
● Jumlah : ....................................................................................
● Cara pemberian : ..................................................................................
● Infus/jumlah : ....................................................................................

b. Pola eliminasi
BAK
● Frekuensi/ jumlah : .............................................................................
● Warna : ...................................................................................
● Berat diapersberisi BAK : ..................cc (1 ml = 0,911 gram)
● Balance cairan : ……………………………………………………..
BAB
● Frekuensi : ...................................................................................
● Warna : ...................................................................................
● Konsistensi : ...................................................................................

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c. Pola istirahat dan tidur
● Lamanya : ...................................................................................
● Keadaan waktu tidur : .........................................................................

8. PEMERIKSAAN FISIK
a. Keadaan umum
................................................................................................................................................................
................................................................................................................................................................
..................................
b. Tanda – tanda vital
Nadi : ....................................... RR : ...............................................
Suhu : .....................................
c. Satus gizi / pertumbuhan
● Berat badan lahir : ………………………………………………………………
● Berat badan : ....................................................................................
● Panjang badan : ....................................................................................
● Lingkar lengan : ....................................................................................
● Lingkar dada : ......................................................................................
● Lingkar kepala : ....................................................................................
d. Pemeriksaan cepalo caudal
1. Kepala dan rambut
● Caput Succedenum : ........................................................................
● Chepal hematoma : ........................................................................
● Fontanela :
Lunak Datar Menonjol Cekung
● Sutura sagitalis
Tepat Terpisah Menjauh Tumpang tindih
● Gambaran wajah :
Simetris Asimetris
● Bentuk kepala : normal/ mikrochepal/ unchepal/ hidrochepal
2. Mata
● Bentuk/simetris : ............................................................................. ….
● Kotoran : ...................................................................................
● Konjungtiva : ...................................................................................
● Sklera : .............................................................................................
● Palpebra : ...................................................................................
● Jarak interkantus : …………………….. cm

3. Hidung

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● Lubang hidung : ................................................................................
● Pernapasan cuping hidung : ...............................................................
● Sekret : ......................................................................................
● Kelainan : ....................................................................................
● Refleks grabella : ................................................................................

4. Telinga
● Bentuk : ....................................................................................
● Letak telinga terhadap mata : .............................................................
● Pengeluaran cairan : ..........................................................................
● Kelainan : ...................................................................................
● Refleks startel : ...................................................................................
5. Rongga mulut dan tenggorokan
● Warna bibir : .......................................................................................
● Palatum : .....................................................................................
● Lidah : ......................................................................................
● Gigi : .....................................................................................
● Refleks sucking : .................................................................................
● Refleks rooting : ...................................................................................
● Refleks gawn : ....................................................................................

6. Leher
● Pembengkakan kelenjar : ...................................................................
● Kelenjar tiroid : .........................................................................
● Reflek tonik neck : .........................................................................
● Kelainan : .........................................................................

7. Dada/thorak
a. Pemeriksaan paru
1. Inspeksi
Bentuk : normal / tidak normal, sebutkan…………
Pengembangan dada : simetris/asimetris
retraksi intercosta : ya/tidak retraksi suprasternal : ya/tidak
pola nafas : normal/tidak, sebutkan…………...
2. Palpasi
Taktil fremitus : sama/tidak, sebutkan……….
3. Perkusi
sonor/hipersonor/dullnes
4. Auskultasi

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vesikuler : bersih/kasar
bronchial : bersih/kasar
bronchovesikuler : bersih/kasar
Down score
Nilai 0 1 2
Frekuensi nafas < 60x/menit 60-80x/menit >80x/menit
Retraksi Tidak ada Retraksi ringan Retraksi berat
Sianosis Tidak ada Hilang dengan O2 Menetap dengan O2
Air entry (udara masuk) Ada Menurun Tidak terdengar
Merintih Tidak ada Terdengar dengan Terdengar tanpa alat
stesokop bantu
Ket: Skor < 4 : gangguan pernapasan ringan
Skor 4-5 : gangguan pernapasan sedang
Skor > 6 : gangguan pernapasan berat (pemeriksaan AGD harus dilakukan)

b. Pemeriksaan jantung
1. Inspeksi
Ictus cordis : ya/tidak, jika ya pelebaran ….. cm
2. Palpasi
Ictus cordis : lemah / kuat / tidak teraba, lokasi :
3. Perkusi
Batas atas :
Batas bawah :
Batas kanan :
Batas kiri :
4. Auskultasi
Suara jantung : BJ I dan BJ II / tambahan, sebutkan :

8. Abdomen
1. Inspeksi
● Bentuk : datar cembung cekung
● Keadaan tali pusat : ..................................................................
● Perdarahan tali pusat : ..................................................................
● Tanda – tanda infeksi : ................................................................
● Hernia umbilikalis : ...................................................................
● Kelainan : .................................................................
2. Auskultasi
Bising usus ......... x/m
3. Palpasi
Palpasi hepar : nyeri tekan/tidak pembesaran hepar : ya/tidak
Palpasi lien : nyeri tekan/tidak palpasi ginjal : nyeri tekan/tidak
4. Perkusi

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Tympani/Hipertympani
9. Ekstrimitas
● Gerakan : Ya Tidak
● Reflek grasping : Ya Tidak
● Refleks moro : Ya Tidak
● Refleks menari : Ya Tidak
● Jari-jari tangan : Ya Tidak
● Akrosianosis : Ya Tidak
● Kelainan tulang : Tidak ada Ada, sebutkan …………………
● Tonus otot : Bugar/Tidakbugar

10. Genetalia dan anus

1. Laki-laki
● Lubang uretra : normal/epispadia/hipospadia
● Testis :1/2
● Lubang anus : ada/tidak ada
2. Perempuan
● Labia mayora : menutup/belum menutup
● Lubang vagina: .............................................................................................
● Lubang uretra : .............................................................................................
● Lubang anus : ada/tidak ada

11. Keadaan punggung

● Spina bifida : ada/tidak ada
● Refleks peres : ada/tidak ada

12. Integumen
● Warna kulit : ..................................................................................
● Sianosis : Pada kuku Pada sekitar mulut
Ekstrimitas atas Ekstrimitas bawah
Seluruh tubuh
● Kemerahan (rash) : Ada Tidak ada
● Tanda lahir :ada/tidak, jika ada sebutkan .............................................
● Turgor kulit : <2 dtk / lebih
● Kelainan : ...................................................................................

13. Skrining nyeri (NIPS pakai score)

no Kategori Skor
1 Ekspresi wajah
Otot wajah rileks 0

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 Otot wajah tegang, alis berkerut, rahang dan dagu 1
mengunci
2 Tangisan
Tenang, tidak menangis 0
Mengerang, sebentar-sebentar menangis 1
Menangis dalam dapat dimasukkan dalam skor ini, jika 2
bayi terintubasi dengan dasar penilaian pergerakan mulut
dan wajah
3 Pola nafas
Rileks, nafas regular 0
Pola nafas berubah : tidak teratur, lebih cepat dari biasanya, 1
tersedak, menahan nafas
4 Tangan
Rileks, otot tangan tidak kaku, kadang fleksi/ekstensi, yang
kaku, meluruskan tangan tapi dengan cepat melakukan
fleksi/ekstensi yang kaku
5 Kaki
Rileks, otot tangan tidak kaku, kadang bergerak tak 0
berarturan
Fleksi/ekstensi, yang kaku, meluruskan tangan tepi dengan 1
cepat melakukan fleksi/ekstensi yang kaku
6 Kesadaran
Tidur pulas atau cepat bangun, alergi dan tenang 0
Rewel, gelisah, dan meronta-ronta 1
Total Skor
Catatan : skor >3 mengindikasikan bahwa bayi mengalami nyeri
Observasi dilakukan setiap shift, saat TTV, dan pasca tindakan

9. PEMERIKSAAN PENUNJANG
Laboratorium

Foto

USG

ECHO

Penunjang lain………

10. PENATALAKSANAAN
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 ANALISIS DATA

Hari/
DATA ETIOLOGI MASALAH
Tgl/ Jam

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 DAFTAR PRIORITAS DIAGNOSIS KEPERAWATAN

TANGGAL: .................................
No. Diagnosis Keperawatan Kode Tanggal Teratasi Ttd

1.

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 RENCANA INTERVENSI

Hari/ Tgl/ DIAGNOSIS KEPERAWATAN

No. Kode SLKI Kode SIKI
Jam (SDKI)

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 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/ No.
Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
Tgl/ Shift Dx

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