FORMAT PENGKAJIAN NEONATUS

NAMA : shelvi kurrotul faize……………………………………………………………

NIM : 192303101127…………………………………………………………………
TINGKAT / SEMESTER : 1A………………………………………………………………………………………
TANGGAL PRAKTIK : ………………………………………………………………………………………
TEMPAT PRAKTIK : ………………………………………………………………………………………
Lembar kerja 1
1. PENGKAJIAN
A. IDENTITAS KLIEN DAN KELUARGA :
Inisial bayi : .BY.NY.K...........................................................................................
Jenis kelamin : perempuan................................................................................................
Nomor gelang : ..........................................................................................................
Tanggal / jam lahir / U m u r :27-07-2017/12:20/2 hari..................................................................
Tanggal MRS / Pukul :27-07-2017/12:20 ...................................................................................
Tanggal Pengkajian / Pukul :28-07-2017/08.00.....................................................................................

Nama informan : .....................................................................

Hubungan dengan pasien : ..........................................................................................................
Pekerjaan : ..........................................................................................................
Pendidikan : ..........................................................................................................
Alamat : ..........................................................................................................
Status : ..........................................................................................................
Golongan darah : ..........................................................................................................

B. RIWAYAT KEPERAWATAN DAN KESEHATAN

1. RIWAYAT NEONATUS
a. Apgar Score / AS : 1’ 5’ 10’
b. Umur kehamilan : .34 minggu..............................................................................................................
c. BBL : 2000 gram...........................................................................................................
d. PBL :45 Cm..............................................................................................................
e. Cara persalinan :...........................................................................................................
f. Indikasi persalinan : . .......................................................................................................................
g. Komplikasi persalinan: .......................................................................................................................
h. Diagnosa medis : .......................................................................................................................

2. RIWAYAT MATERNAL
a. Umur : .......................................................................................................................
b. G ..... P .................
c. Cara persalinan : .......................................................................................................................
d. Indikasi : .......................................................................................................................
e. Kehamilan
ANC : .......................................................................................................................
Kondisi Hamil : .......................................................................................................................

C. PEMERIKSAAN FISIK
1. Keadaan umum: .......................................................................................................................
a. Kesadaran : .......................................................................................................................
b. BB :1700 gram............................................................................................................
c. PB :41 cm.......................................................................................................
2. Tanda-tanda vital
a. Suhu :37,6 ◦C di bawah lampu penghangat (selama 2 hari)................................................................
b. Nadi :136x/menit........................................................................................................
c. RR :76x/menit.........................................................................................................
d. TD : .......................................................................................................................
3. Reflek
a. Moro :ada/lemah.........................................................................................................
b. Sucking :ada.............................................................................................................
c. Menelan :tidak ada...........................................................................................................
d. Rooting :tidak ada......................................................................................................
e. Reflek primitif lain : .......................................................................................................................

4. Kepala
a. Fontanela :ada ..................................................................................................
b. Sutura :ada.............................................................................................................
c. Molding : tidak ada................................................................................................................
d. Rambut :ada.................................................................................................................
e. Caput succedanium :tidak ada..........................................................................................................
f. Caput haematoma :tidak ada............................................................................................................

5. Telinga Hidung dan Tenggorokan

a. Telinga : .......................................................................................................................
b. Hidung : .......................................................................................................................
c. Palatum : .......................................................................................................................

6. Dada
a. Thorak : .......................................................................................................................
b. Klavikula : .......................................................................................................................

7. Paru
Inspeksi:terdapa tretraksi dada tingkat berat ,bentuk dada simetris,terdapat penggunaan otot bantu nafas nilai RR
76x/menit.
Auskultasi:........................................................................................................................................................................
.................................................................................................................................

8. Jantung
...........................................................................................................................................................................................
...............................................................................................................................................................

9. Abdomen
...........................................................................................................................................................................................
...............................................................................................................................................................

10. Ekstremitas
...........................................................................................................................................................................................
...............................................................................................................................................................

11. Genitalia
...........................................................................................................................................................................................
...............................................................................................................................................................

12. Anus
...........................................................................................................................................................................................
...............................................................................................................................................................

13. Kulit
...........................................................................................................................................................................................
...............................................................................................................................................................
14. Kelainan Kongenital
..................................................................................................................................................................................

D. PEMERIKSAAN PENUNJANG
1. Laboratorium
...........................................................................................................................................................................................
...........................................................................................................................................................................................
......................................................................................................................................

2. Radiologi
...........................................................................................................................................................................................
...........................................................................................................................................................................................
......................................................................................................................................

3. USG
...........................................................................................................................................................................................
...........................................................................................................................................................................................
......................................................................................................................................

4. Lain-lain
...........................................................................................................................................................................................
...........................................................................................................................................................................................
......................................................................................................................................

E. DIAGNOSA MEDIS
...........................................................................................................................................................................................
...........................................................................................................................................................................................
......................................................................................................................................

F. PENATALAKSANAAN TERAPI
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
................................................................................................................
 Lembar kerja 2
Data objektif:
Normal Abnormal
RR:76x/menit HB:17,8
N:136 x/menit. ctus cordis teraba di
S:37,6◦C ICS 5 MCL

Data subjektif:
1.di data tersebut tertulis inspekti terdapat retraksi dada tingkat berat RR 76x/menit.
2.suara nafas menurun
3.bentuk dada normocest
4.ICS tidak tampak.
5.bising usus 10x/menit
6.tali pusar masih basah.
 Lembar 3
Domain:4
Kelas :4
Kode:00032
(ketidak efektifan pola nafas)
 Lembar kerja 4
1.penurunan tekanan adalah penurunan tekanan dinding dada ketika menarik napas keluar.

Lembar kerja 5
No Data Penyebab Masalah
1 Ds: Penurunan tekanan Ketidak efektifan pola
Suara nafas menurun dinding ketika napas.
menarik napas.

Masalah keperawatan
1.penurunan tekanan dengan ketidak efektifan pola nafas berhubungan dengan suara nafas
menurun.

Daftar prioritas diagnosa keperawatan.

Ketidak efektifan pola nafas berhubungan dengan suara nafas menurun.