KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN JAMBI

JURUSAN KEPERAWATAN
Jl. Dr. Tazar No. 05 Buluran Kenali Telanaipura Jambi 36123 Telp. ( 0741 ) 65816

ASUHAN KEPERAWATAN PADA BAYI DAN ANAK

RIWAYAT KEPERAWATAN

1. TANGGAL PENGKAJIAN : ...................................

: ............................
NAMA MAHASISWA : ......................
2. TANGGAL MASUK : ..................................
...... NIM : ......................
3. JAM MASUK TANDA TANGAN : ......................
4. RUANGAN/ KELAS : ..................................
5. NOMOR KAMAR : ..................................
6. NO. REGISTER : ..................................
7. DIAGNOSA MEDIS : ..................................
A. PENGKAJIAN

1. IDENTITAS
a. Nama Bayi/ Anak : .......................................................................................
b. Umur : ........................................................................................
c. Berat Badan : ........................................................................................
d. Nama Ayah : ........................................................................................
e. Umur : ........................................................................................
f. Pendidikan : ........................................................................................
g. Pekerjaan : ........................................................................................
h. Agama : ........................................................................................
i. Alamat : ........................................................................................
j. Nama Ibu : ........................................................................................
k. Umur : ........................................................................................
l. Pendidikan : .......................................................................................
m. Pekerjaan : ........................................................................................
n. Agama : ........................................................................................
o. Alamat : ........................................................................................
2. Alasan masuk RS ........................................................................................ :
3. Keluhan Utama / Chief Complain : .........................................................................
(Saat pengkajian) ………………………………………………...

4. Riwayat Kesehatan Sekarang ( PQRST ) : ........................................................................

..........................................................................
..........................................................................
..........................................................................
..........................................................................
..........................................................................
5. Riwayat Kesehatan Yang lalu : ……………………………………………….
a. Penyakit waktu kecil/yang lalu : ……………………………………………….
b. Pernah dirawat ( hospitalisasi) : ……………………………………………….
c. Obat-obatan : ……………………………………………….
d. Operasi : ……………………………………………….
e. Alergi : ……………………………………………….
f. Kecelakaan : ……………………………………………….
g. Lain-lain : ……………………………………………….
6. Riwayat penyakit keluarga
a. Penyakit yang pernah diderita keluarga: ……………………………………………….
b. Keluarga yang menderita penyakit keturunan; DM,Asthma : ………………………….
c. Keluarga yang menderita penyakit menular; TBC,hepatitis,peny.kulit :……………….
d. Genogram (Minimal 3 generasi)

7. Riwayat Kehamilan dan Persalinan :

A. Antenatal ( Prenatal ) : ( Usia < 2 thn)
: .........................................................................
a. Kesehatan Ibu
: .........................................................................
b. Berapa kali kunjungan
c..Adakah dalam pengobatan : ……………………………………………….
: .........................................................................
- Diet
: .........................................................................
- Infeksi
: .........................................................................
d. Adakah dilakukan RO
: .........................................................................
e. Adakah tanda-tanda Pre eklampsia
: .........................................................................
f.. Tempat pemeriksaan Kehamilan
: .........................................................................
g. Ketergantungan Obat-obatan
B. Natal : ( Usia < 2 thn)
: .........................................................................
a. Usia Kehamilam
b. Berat Badan Lahir : < 2500 gr 2500 –3000 gr > 3000 gr
c. Jenis dan Lama Persalinan :
SpontanVacum ekstraksi InduksiSectio caesaria
: .........................................................................
d. Keadaan anak setelah Lahir
- Segera menangis : Ya tidak
- Resusitasi : dilakukan tidak dilakukan
e. Obat yang digunakan selama persalinan : ...................................................................

C. Neonatal ( Post Natal ) ; Usia 0-28 hari

a. Apgar Score : <6 6-7 8-10
b. Kelainan Kongenital : .........................................................................
c. Warna Kulit :
- Cyanosis : .........................................................................
- Kuning/Icterus : .........................................................................
d. Panas : .........................................................................
e. Kejang : .........................................................................
f. Adakah kesulitan dalam menelan, :
menghisap atau minum : .........................................................................
g. Mengukur Perkembangan
- Motorik Halus : .........................................................................
- Motorik Kasar : .........................................................................
-Bahasa : .........................................................................
- Lingkar kepala :
……………………………………………….
- Lingkar dada :
……………………………………………….
- Panjang Badan :
……………………………………………….
- Berat badan :
……………………………………………….

8. Kebutuhan Dasar
1. Makan (dirumah)
a. Jenis Minuman ( ASI/PASI ) : ................................................................
b. Interval Minum : ................................................................
c. Waktu yang dibutuhkan untuk minum : ................................................................
 d. jumlah minum ( Sekali minum )
e. Waktu untuk pengenalan makanan
tambahan
f. Nafsu makan
g. Jenis makanan
g. Makanan yang disukai
h. Alergi
i. Kebiasaan makan
j. Pantangan
k. Alat yang digunakan
2. Makan (di Rumah sakit))
a. Jenis Minuman ( ASI/PASI )
b. Interval Minum
c. Waktu yang dibutuhkan untuk minum
d. jumlah minum ( Sekali minum )
e. Waktu untuk pengenalan makanan
tambahan
f. Nafsu makan
g. Makanan yang disukai
h. Alergi
i. Kebiasaan makan
j. Pantangan
k. Alat yang digunakan
3. Pola Tidur (dirumah)
a. Berapa jam
b. Gangguan saat tidur
c. Hal yang memudahkan tidur
( Boneka/Dongeng/Selimut/Bantal dll )
4. Pola Tidur (dirumah sakit)
a. Berapa jam
b. Gangguan saat tidur
c. Hal yang memudahkan tidur
( Boneka/Dongeng/Selimut/Bantal dll )
5. Bermain dan Istirahat (dirumah)
a. Berapa jam istirahat
b. Bermain
- Waktu
- Jenis
- Teman
- Tempat
- Hubungan dengan teman
6. Bermain dan Istirahat (dirumah sakit)
a. Berapa jam istirahat
b. Bermain
- Waktu
- Jenis
- Teman
- Tempat
7. Hygiene (dirumah)
- Berapa kali mandi
- Berapa kali gosok gigi
: ................................................................
: ................................................................
: ................................................................
makanan segarmakanan diawetkanInstan
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: ................................................................
: ................................................................
: ................................................................
 - Mandi pakai apa : ................................................................
- Kebersihan rambut / kuku : ................................................................
8. Hygiene (dirumah sakit)

- Berapa kali mandi : ................................................................

- Berapa kali gosok gigi : ................................................................
- Mandi pakai apa : ................................................................
- Kebersihan rambut / kuku : ................................................................
9. Imunisasi

- Dasar < 1 tahun : ................................................................

- Ulangan 1 th – usia sekolah : ................................................................
B. Hasil perkembangan

a. Motorik Kasar
Usia 1-4 bln
 Mengangkat kepala saat tengkurap .......................................................... Ya tidak
 Dapat duduk sebentar dgn ditopang .......................................................... ya tidak
 Dapat duduk dgn kepala tegak .................................................................. ya tidak
 Jatuh terduduk dipangkuan ketika disokong saat berdiri ......................... Ya tidak
 Kontrol kepala dgn sempurna ................................................................... ya tidak
 Mengangkat Kepala sambil berbaring telentang ....................................... ya tidak
 Berguling dari telentang kemiring ............................................................. ya tidak
 Posisi lengan dan tungkai lebih fleks ........................................................ ya tidak
 Berusaha untuk merangkak ....................................................................... ya tidak
Usia 4-8 bln

 Menahan kepala tegak lurus ..................................................................... Ya tidak

 Berguling dari telentang ketelungkup ....................................................... ya tidak
 Dapat duduk dgn bantuan selama interval singkat ................................... Ya tidak
Usia 8-12 bln

 Duduk dari tegak tanpa bantuan ................................................................ ya tidak

 Dapat berdiri tegak dgn bantuan .............................................................. Ya tidak
 Berdiri tegak tanpa bantuan walaupun sebentar ....................................... Ya tidak
 Membuat posisi merangkak ...................................................................... ya tidak
 Merangkak............................................................................ ya tidak
 Berjalan dgn bantuan ........................................................................... Ya tidak
b. Motorik Halus

Usia 1 – 4 bln
 Melakukan usaha untuk memegang suatu objek ...................................... Ya tidak
 Mengikuti objek dari sisi kesisi ................................................................ Ya tidak
 Mencoba memgang benda tapi terlepas ................................................... Ya tidak
 Memasukan benda kedalam mulut ........................................................... Ya tidak
 Memperhatikan tgn dan kaki .................................................................... Ya tidak
 Memegang benda dan kedua tgn .............................................................. Ya tidak
 Menahan benda ditgn walaupun sebentar ................................................ Ya tidak
Usia 4-8 bln

 Menggunakan ibu jari dan jari telunjuk untuk memgang ........................ Ya tidak
 Mengeksplorasi benda yang sedang dipegang ......................................... Ya tidak
 Mampu menahan kedua benda dikedua tgn secara simultan ................... Ya tidak
 Memindahkan objek dari satu tgn ketgn lain ........................................... Ya tidak
 Usia 8 – 12 bln
 Melepas objek dgn jari lurus .................................................................... Ya tidak
 Mampu menjepit benda ........................................................................... Ya tidak
 Melambaikan tgn ........................................................................... Ya tidak
 Menggunakan tangan untuk bermain ....................................................... Ya tidak
 Menempatkan objek kedalam wadah ....................................................... Ya tidak
 Makan biscuit sendiri ........................................................................... Ya tidak
 Minum dari cangkir dgn bantuan ............................................................. Ya tidak
 Makan dgn jari ........................................................................... Ya tidak

c. Bahasa : .........................................................................
C. Pemeriksaan fisik

a. Tanda-tanda vital
- Tekanan Darah ……..mmHg
Mean Pressure : ...........................................................................................
- Suhu : ...........................................................................................
- Nadi : ...........................................................................................
- Pernafasan : ...........................................................................................
b. Keadaan Umum

- Penampilan : ...........................................................................................
- Kesadaran
Kuantitatif (GCS):E=……
M= ……
V=……
Jumlah : ……….
Kualitatif Composmentis Apatis Delirium Confulsi
Samnolen Semi coma Coma
- Tinggi Badan : ...........................................................................................
- Berat Badan : ...........................................................................................
- Lingkar kepala (<2th) ............................................................................................
- Lingkar dada(< 2th) ............................................................................................
c. Kepala

- Struktur Simetris AsimetrisCaput succaedenum

- Fontanela Menonjol RataCekung
- Kulit kepala BersihKotorhematomalesi kerniks
caseosa
- Nyeri / Pusing ada tidak
- Rambut
Distribusi ............................................................................................
Warna ............................................................................................
- Keluhan lain : ...........................................................................................
d. Ma ta / Penglihatan

- Ketajaman Jauh………… Dekat………

- Sklera Putihmerahicterus
- Pupil
Ukuran isokor Anisokor
Reflek terhadap cahaya Miosis midriasis
- Konjungtiva merah MudaPucat merahLain-lain.
- Gerak bola mata : ...........................................................................................
- Refleks kornea : ...........................................................................................
- Kelopak mata Normal Ptosis Edema
Lain-lain,jelaskan…………..
 - Alat Bantu penglihatan kaca matalensa kontak
- Sekret Ada Tidak
e. Hidung / Penciuman
: ...........................................................................................

- Struktur : ...........................................................................................

- Fungsi : ...........................................................................................

- Perdarahan : ...........................................................................................

- sinus/polip
- Cairan/lendir : ada tidak
f. Rongga mulut

- Mukosa mulut Lembab KeringSariawan

- Lidah Bersih Kotor Lesipecah
- pembesaran tonsil ada merahAbses membran putih Tidak
ada
- nyeri menelan ada tidak
- Gigi Bersih Berlubang+caries
lengkaptidak lengkap
g. Telinga / Pendengaran
- Struktur Simetris Asimetris
- FungsiBaik
Test detik arloji……………….
Test dgn menggesek
tangan/rambut Test garputala
Test Swabach
Test weber
Test rinne

- Nyeri : ...........................................................................................
- Serumen : ...........................................................................................
- Ciran telinga : ...........................................................................................
h. Leher

- Distensi vena yugolaris : ...........................................................................................

- pembesaran thyroid adatidak
- pembesaran kelenjar getah beningada Tidak
- kaku kuduk Ada Tidak
i. Pernapasan

- Kualitas nafas DalamDangkal Cepat lambat

- Bunyi nafas Vesicular Rales Ronchi
WheezingPleural Friction rub
- Tipe / Pola Teratur Dispnoe OrthopnoeCheynestokes
biotKussmaul
: ...........................................................................................
- Batuk
: ...........................................................................................
- Sputum
- Struktur dada Simetris Asimetris
- Bentuk thoraks Normal Pigeon chest Funnel chest Barrel chest
- Pemeriksaan Rontgen : ...........................................................................................
- Penggunaan otot Bantu pernapasan .......................................................................... :
Retraksi supraklavikular Retraksi sub kostal
Retraksi interkostal Retraksi suprasternal
- Penggunaan alat Bantu pernapasan
O2…………l/mntVentilator
j. kardiovaskuler
- Ukuran jantungnormal ICS- 5 Kardiomegali lain-lain,jelaskan……
- Nyeri dada ada Tidak
- Palpitasi ada tidak : ...........................................................................................

- Denyut jantung
- Bunyi jantung S1/S2 Murmur Gallop
- Sianosis Ada Tidak
- Jari-jari tabuh/Clubbing finger ada tidak ; ...........................................................................................

- CRT : ...........................................................................................

- Lain-lain
k. Abdomen

- Struktur Simetrisasimetris
- Nyeri tekan Ada Tidak ada
- Bising usus : ………..x/Menit
: ...........................................................................................

- Benjolan
- Pembesaran hati ada tidak
- pembesaran limfa ada tidak
- kembung Ada Tidak
- Mual ada Tidak ada
- Muntah
: ...........................................................................................
- Frekuensi
: ...........................................................................................
- Jumlah
............................................................................................
- karakteristik
............................................................................................
- Mulas
............................................................................................
- Ascites
............................................................................................
- Keadaan lainnya
l. Kulit :

- Ptekie/ekimosis Ya Tidak
- Turgor Jelek Baik
: ...........................................................................................
- Lesi
: ...........................................................................................
- Kelembaban
: ...........................................................................................
- Diaforesis
: ...........................................................................................
- Sianosis
: ...........................................................................................
- Lain-lain
m. Eliminasi

- Frekuensi BAK/24 jam : ...........................................................................................

- Jumlah urine : …………cc/24 jam
- Keluhan BAK Nyeri Inkontinensia
Jelaskan ............................................................................................

- Penggunaan kateter Ya Tidak

- Karakteristik urine
Warna jernih keruh Merah
Bau ammoniaAseton Pesing/Khas
- Frekuensi BAB/24 jam : ...........................................................................................
- Keluhan BAB KonstipasiDiareTenesmus
- karakteristik Feses Cair Berlendir Berdarahada ampas
Lunak keras lain-lain, jelaskan …………………
- Colostomi ............................................................................................

n. Muskuloskeletal
............................................................................................
- kekuatan otot
............................................................................................
- Tonus otot
............................................................................................
- Fraktur
 - Atropi ............................................................................................
- Edema ............................................................................................
- Persendian
a. Rentang gerak Terbatas Jelaskan…….. Bebas/aktif kaku sendi
b. Kontraktur Ada Tidak
c. Tanda-tanda radang Nyeri edema merah PanasFunctiolasea

- tulang belakangSkoliosis Kyposis Lordosis Tak ada kelainan

- Aktivitas MandiriBantuan sebagian Bantuan sepenuhnya
o. Neurology

- Fungsi Nervus I ............................................................................................

- Fungsi nervus II ............................................................................................
- fungsi nervus III ............................................................................................
- Fungsi nervus IV ............................................................................................
- Fungsi nervus V ............................................................................................
- Fungsi nervus VI ............................................................................................
- Fungsi nervus VII ............................................................................................
- Fungsi nervus VIII ............................................................................................
- Fungsi nervus IX ............................................................................................
- Fungsi nervus X ............................................................................................
- Fungsi nervus XI ............................................................................................
- Fungsi nervus XII ............................................................................................
- Aktivitas kejang
jenis ............................................................................................
Lama ............................................................................................
- kelumpuhan ............................................................................................
- Reflek patologis
Babinski yatidak
- Fungsi sensoris
a.Reaksi terhadap nyeri ....................................................... Ada tidak ada
b.Reaksi terhadap suhu ................................................. ada tidak ada
c.Reaksi thd raba........................................................... ada tidak ada

- Afek
a. Emosi Labil stabil
b. alam perasaan Sedih Gembira Cemas Lain-
lain,sebutkan………………
- Orientasi
a. Waktu ............................................................................................
b. Tempat ............................................................................................
8. Orang ............................................................................................

1. Genitalia
Struktur ............................................................................................
Kelainan ............................................................................................
Iritasi ada tidak
Sekret ada tidak
Anus Normal Atresia ani

2. Psikososial
Hubungan dgn keluarga............................................................................................
Pola interaksi............................................................................................
Komunikasi............................................................................................
Norma dan keyakinan yang dianut ...........................................................................................
Tanggapan keluarga ttg penyakit ............................................................................................
13. Diagnosa medis : ...........................................................................................
14. Hasil Pemeriksaan Penunjang :

- Laboratorium : ...........................................................................................
urine : ...........................................................................................
Darah : ...........................................................................................
Sputum : ...........................................................................................
: ...........................................................................................
- X-Ray / ECG : ...........................................................................................
: ...........................................................................................
: ...........................................................................................
- Lain-lain : ...........................................................................................
: ...........................................................................................
: ...........................................................................................
15. Program Pengobatan Dokter : ...........................................................................................

: ...........................................................................................
: ...........................................................................................
: ...........................................................................................

16. Catatan Tambahan : ...........................................................................................

: ...........................................................................................
: ...........................................................................................
: ...........................................................................................

17. Ringkasan secara umum tentang pasien : ...............................................................................

: ..............................................................................
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.
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.
Yg melakukan Pengkajian

( ……………………….. )
NIM.
ANALISA DATA

NO DATA PENYEBAB MASALAH

1. Data subjektif :
 ……………………….
 ……………………….
 ……………………….
 ……………………….
Data Objektif
 ……………………….
 ……………………….
 ……………………….
 ……………………….
 ……………………….

2. Data subjektif :
 ……………………….
 ……………………….
 ……………………….
 ……………………….
Data Objektif
 ……………………….
 ……………………….
 ……………………….
 ……………………….
 ……………………….

3. Data subjektif :
 ……………………….
 ……………………….
 ……………………….
 ……………………….
Data Objektif
 ……………………….
 ……………………….
 ……………………….
 ……………………….
 ……………………….

4. Data subjektif :
 ……………………….
 ……………………….
 ……………………….
 ……………………….
Data Objektif
 ……………………….
 ……………………….
 ……………………….
 ……………………….
 ……………………….
 KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN JAMBI
JURUSAN KEPERAWATAN
Jl. Dr. Tazar No. 05 Buluran Kenali Telanaipura Jambi 36123 Telp. ( 0741 ) 65816

ASUHAN KEPERAWATAN BAYI BARU LAHIR

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

1. TANGGAL PENGKAJIAN : : ............................

NAMA MAHASISWA : ......................
2. TANGGAL MASUK ...... NIM
: ..................................
: ......................
3. JAM MASUK TANDA TANGAN : ......................
4. RUANGAN/ KELAS : ..................................
5. NOMOR KAMAR : ..................................
6. NO. REGISTER : ..................................
7. DIAGNOSA MEDIS : ..................................
I. PENGKAJIAN

IDENTITAS
a. Nama Ibu : .......................................................................................
b. Umur Ibu : ........................................................................................
c. Tanggal lahir bayi : ........................................................................................
d. Tanggal Pemeriksaan : ........................................................................................
e. HPHT : ........................................................................................
f. Perkiraan umur kehamilan : ........................................................................................
g. Apgar score 1 menit : ........................................................................................
h. Berat badan lahir : ........................................................................................
i. Kekurangan berat badan : ........................................................................................
m. Pengukuran
- Panjang : ........................................................................................
- Lingkar Kepala : ........................................................................................
- Lingkar dada : ........................................................................................
- Denyut jantung/menit : ........................................................................................
- Pernapasan : ........................................................................................
- Bunyi paru
* Kiri : ........................................................................................
* Kanan : ........................................................................................
- Temperatur/suhu : ........................................................................................
n. Pengkajian umum
- Kepala
* Caput Succedanium .........................................................................................
* Chepalo Hematoma .........................................................................................
* Fontanel anterior .........................................................................................
* Fontanel posterior .........................................................................................
* Sutura .........................................................................................
* Gembung/cekung .........................................................................................
* Tanda pada kepala .........................................................................................
- Telinga
* Posisi .........................................................................................
* Tulang rawan .........................................................................................
- Mulut
* Simetris .........................................................................................
* Palatum Keras .........................................................................................
* Palatum lunak .........................................................................................
* Gigi .........................................................................................
 - Leher
* Gerakan leher .........................................................................................
- BAK pertama tanggal .........................................................................................
Berapa jam setelah lahir .........................................................................................
- BAB pertama tanggal .........................................................................................
Berapa jam setelah lahir .........................................................................................
- Minum .........................................................................................
- Reflek
* Menghisap .........................................................................................
* Menggenggam .........................................................................................
* Moro .........................................................................................
* Stapping .........................................................................................
* Tonick neck .........................................................................................
- Menangis .........................................................................................

p. Kondisi keseluruhan .........................................................................................

.........................................................................................
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q. Kesimpulan menemukan yang normal:
.........................................................................................
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.........................................................................................
r. Riwayat singkat prenatal dan persalinan:
- Masalah selama kehamilan .........................................................................................
.........................................................................................
.........................................................................................
.........................................................................................
.........................................................................................
- Lamanya: Kala I .........................................................................................
Kala II .........................................................................................
- Pecahnya ketuban sebelum lahir ...................................................................................
- Warna Ketuban .........................................................................................
- Jenis persalinan .........................................................................................
- Resusitasi yang dilakukan untuk bayi ...........................................................................

Yg melakukan Pengkajian

( ……………………….. )
NIM.