PENGKAJIAN NEONATUS SAKIT / RISIKO TINGGI

A. IDENTITAS NEONATUS
Nama Bayi :
Tanggal Lahir : Jam :
Jenis : Laki – Laki / Perempuan
Umur :
Ruang :
Kelahiran : tunggal/kembar, hidup/mati
Tanggal MRS : Jam :
Tanggal Pengkajian : Jam:
Diagnosa medis :
B. IDENTITAS ORANG TUA
Nama Ibu : Nama Ayah :
Umur Ibu : Umur Ayah :
Pekerjaan Ibu : Pekerjaan Ayah:
Pendidikan Ibu : Pendidikan Ayah:
Agama :
Alamat :
Dikirim Oleh :

C. RIWAYAT KEHAMILAN DAN PERSALINAN :

1. Riwayat Kehamilan
Ibu (G) P A
BB………………… kg , Umur Kehamilan ………………..minggu/bulan
TB………………… cm
Pemeriksaan antenatal …………………kali di…………
Teratur/tidak teratur, sejak kehamilan……………….minggu
Penyakit/komplikasi kehamilan……………………………………………..
Kebiasaan makanan IBU ………….........
Merokok…….. ya/tidak
Jamu…………………….ya/tidak
Kebiasaan minum obat………… ya/tidak
Periksa terakhir :
Hb gr% Golongan Darah……………….
Gula Darah ……………….mg% Lain – Lain………………
Pernah mendapat terapi…………. Alergi obat ....................................

2. Riwayat Persalinan
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
D. RIWAYAT KEPERAWATAN
1. Riwayat Keperawatan Sekarang :
a. Keluhan utama :

b. Riwayat penyakit Sekarang : (awal sakit hingga saat ini)

 2. Riwayat Keperawatan Sebelumnya :
a. Riwayat Kesehatan yang lalu :

b. Imunisasi yang telah didapatkan :

3. Riwayat Keluarga
Genogram :

4. Riwayat Pertumbuhan dan perkembangan

Tahap Pertumbuhan
a. Berat badan lahir : gr Berat badan sekarang : gr
b. Lingkar Kepala : cm Lingkar Dada : cm
Lingkar Abdomen : cm Lingkar Lengan Atas : cm
c. Panjang Badan : cm
Tahap Perkembangan
a. Psikososial :

b. Psikoseksual :

c. Kognitif :

Kebutuhan dasar
a Nutrisi :
b Eliminasi :
c Istirahat tidur :
d Personal Hygiene :

5. Pengkajian fisik
a. Tanda – Tanda Vital :
Nadi : x/menit Suhu : °C
Pernafasan : x/menit, Tekanan Darah : mmHg
CRT : Lainnya :
b. Pemeriksaan Fisik
 Kulit :
 Kepala :

 Mata :

 Hidung :

 Telinga:

 Mulut/Lidah :

 Leher :

 Dada :
- Jantung (Inspeksi, Palpasi, Perkusi, Auskultasi)

- Paru – Paru (Inspeksi, Palpasi, Perkusi, Auskultasi):

 Abdomen (Inspeksi, Palpasi, Perkusi, Auskultasi)1:

 Anus :

 Genital :

 Ektremitas

 Refleks ;
a. Sucking (menghisap) :

b. Palmar Grasping (menggenggam) :

c. Tonic Neck (leher) :

d. Rooting (mencari) :

e. Moro (kejut)

f. Babinsky :

g. Gallant (punggung) :

h. Swallowing (menelan) :
 i. Plantar Grasping (telapak kaki) :

c. Riwayat Nilai APGAR

1 menit 5 menit 2 jam
Activity (Muscle Tone)
Pulse (Heart Rate)
Grimace (Reflex Irritability)
Appearance (Color)
Respiration Rate
Interpretasi =
d. Down Score
Skor 0 1 2 Hasil
Frekuensi < 60 60-80 >80
Sianosis - Menghilang dengan oksigen 40% Perlu oksigen 80%
Retraksi - Sedang Berat
Merintih - Minimal Jelas
Aliran udara Baik Menurun Sangat Jelek
Down score =
e. Kramer Test =

f. Risiko Jatuh = Risiko rendah Risiko Tinggi

g. Pengkajian nyeri (NIPS), Oucher

h. Ballard Score : ..........= ......minggu

E. PEMERIKSAAN PENUNJANG :
Tgl Tgl

F. TERAPI:
Tgl Tgl

ANALISA DATA
Nama Pasien : Ruang :
Umur : Hari/tgl :
No Data Etiologi Problem/Masalah

PRIORITAS MASALAH
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RENCANA KEPERAWATAN
Nama Pasien : Ruang :
Umur : Hari/tgl :
Diagnosa Tujuan (NOC) Intervensi (NIC) AKTIFITAS
 CATATAN PERKEMBANGAN

Diagnosa Keperawatan: ..........................................................................................................................................................................................................

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Hari/Tgl/Jam Implementasi Paraf Evaluasi (SOAP)