LAPORAN ASUHAN KEPERAWATAN PADA Bayi .........

DENGAN ......................................................................

A. PENGKAJIAN
I. IDENTITAS

Nama : .....................................

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

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

Pekerjaan : .....................................

Nama orang tua : .....................................

Tanggal MRS : .....................................

Tanggal pengkajian : .....................................

Sumber informasi : .....................................

No CM. : .....................................

II. RIWAYAT KELAHIRAN YANG LALU

No
Tahun kelahiran Sex BB lahir Keadaan bayi Komplikasi Jenis persalinan Ket
.

III. RIWAYAT PERSALINAN

 BB/TB ibu
 Persalinan di
 Keadaan umum ibu
 Tanda Vital
 Jenis persalinan
 Proses Persalinan
 Kala I
Indikasi
: ...........kg/...........cm
: ..............................
: ..............................
: ..............................
: ..............................
: ..............................
: ....... jam
: ..............................
  Kala II : ......menit
Komplikasi persalinana ibu : .................. Janin : .....................

Lamanya ketuban pecah : ......................... Kondisi ketuban : ..........................

IV. KEADAAN BAYI SAAT LAHIR

 Lahir tanggal : ……………………
 Jam : ……………………
 Sex : ..........……………
 Kelahiran : tunggal/gemeli

Nilai APGAR

Nilai
Tanda Jumlah
0 1 2

Appearance color Pucat/biru Tubuh kemerahan, tangan Kemerahan seluruh tubuh

(warna kulit) dan kaki biru

Pulse Tidak ada <100 >100

(denyut jantung)

Grimace Tidak ada Sedikit gerakan mimik Menangis, batuk, bersin

(reaksi terhadap
rangsangan)

Activity Lumpuh Ekstremitas fleksi sedikit Gerakan aktif

(tonus otot)

Respiratory Tidak ada Lemah tidak teratur Menangis kuat

(usaha napas)

V. PEMERIKSAAN FISIK
 Berat badan : ..........................................
 Panjang badan : ..........................................
 Suhu : ..........................................
 Lingkar kepala : ..........................................
 Lingkar dada : ..........................................
 Lingkar perut : ..........................................
 Tubuh:
Warna : ..................................................

Lanugo : ..................................................

Vernix : ..................................................
Head to Toe :

1) Kepala Wajah
Inspeksi

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Palpasi

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Mata

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Telinga

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Hidung

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Mulut

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
 ....................................................................................................................................
2) Leher
Inspeksi

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Palpasi

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
3) Dada
Inspeksi

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Palpasi

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Perkusi

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

Auskultasi
 ....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
4) Abdomen
Inspeksi

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Auskultasi

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Perkusi

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Palpasi

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Keadaan tali pusat

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
5) Punggung
Keadaan punggung
 ....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Fleksibilitas

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Tulang punggung

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Kelainan

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
6) Genetalia dan anus
Mekonium

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Kelainan

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
7) Ekstremitas
Atas
 ....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Bawah

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Kelainan

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Pergerakan

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

8) STATUS NEUROLOGI
Pemeriksaan reflek

Refleks moro : ....................

Refleks rooting : ....................

Sucking refleks : ....................

Ballard score : ....................

9) PEMERIKSAAN PENUNJANG
 Pemeriksaan Laboratorium :
....................................................................................................................................
 ....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
 Radiologi :
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
10) Diagnosa Medis

.......................................................................................................................................
.......................................................................................................................................
 .......................................................................................................................................
.......................................................................................................................................

11) Pengobatan

.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................

B. ANALISA DATA

Tanggal/
No Data Fokus Etiologi Masalah
Jam
Diagnosa keperawatan berdasarkan prioritas:

1…………………………………………………………................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
.......................................................................................................................................................................

2…………………………………………………………………....................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................

3…………………………………………………………………....................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
...........................................................................................................................................

C. RENCANA KEPERAWATAN

NO DIAGNOSA RENCANA KEPERAWATAN

 TUJUAN INTERVENSI RASIONAL

D. IMPLEMENTASI
HARI, NO. IMPLEMENTASI EVALUASI/ PARAF/
TGL DX RESPON KLIEN NAMA
JAM

E. EVALUASI/ CATATAN
HARI,
NO.
TGL EVALUASI PARAF
DIAGNOSA
JAM

Denpasar, ..................................2014
Mengetahui,
Pembimbing klinik/CI Mahasiswa,

(.............................................................) (........................................................)
NIP. NIM.

Pembimbing klinik/CT

(......................................................................)
NIP.