ASUHAN KEPERAWATAN NEONATAL

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PENGKAJIAN

Tanggal MRS/Jam :

Tanggal Pengkajian/Jam :

Tempat :

A. DATA SUBYEKTIF

1. Identitas

Nama Bayi   :................................................................................................................

Tanggal/JamLahir  :.................................................................................................................

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

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

DxMedis :...............................................................................................................

2. Keluhan Utama           

a) Saat MRS

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b) Saat Pengkajian

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3. Identitas Orang Tua

Ayah Ibu

Nama : :

Umur : :

Suku/Bangsa : :

Agama : :

Pendidikan : :

Pekerjaan : :

Alamat : :
4.Riwayat Prenatal

- Kehamilan  ke:......................................................................................................................

- Tempat ANC :......................................................................................................................

- Imunisasi TT  :.....................................................................................................................

- Obat-Obatan yang pernah diminum selama hamil:..............................................................

- Penerimaan Ibu/Keluarga Terhadap kehamilan  :.................................................................

- Masalah yang pernah dialami ibu saat hamil:.......................................................................

4. Riwayat IntraNatal

- Persalinan ke    :....................................................................................................................

- Tempat dan penolong persalinan   :......................................................................................

- Masalah saat persalinan    :..................................................................................................

- Jenis Persalinan :...................................................................................................................

- Lama persalinan:.......................................................................................                           

- Keadaan bayi saat lahir:........................................................................................................

- Segera menangis/tidak:..................................................................................                      

5. Riwayat Natal

- Keadaan bayi baru lahir

- Lahir tanggal : .....................................,jam..........................................................

- Masa gestasi : ........................................ minggu

- BB/PB lahir :.........................gram, ......................cm

- Nilai APGAR : 1 menit/5menit/10 menit/2 jam:

 No Kriteria 1 menit 5 menit 10 menit 2 jam

1 Denyut Jantung

2 Usaha nafas

3 Tonus otot

4 Reflek

5 Warna kulit

TOTAL

6. Pola Fungsi kesehatan

Kebutuhan Dasar Saat MRS Saat Pengkajian

1. Cairan &

Makanan

2. Eliminasi

3. Istirahat & Tidur

4. Personal hygiene

5. Aktivitas

7. Status Imunisasi

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B. DATA OBJEKTIF

1.  Pemeriksaan Umum
a. Keadaan umum :

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b. kesadaran :

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c. Tanda vital

Nadi

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Pernafasan

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Suhu

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2. Pemeriksaan Antropometri

BB

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PB

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LK

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LD

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LLA

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2.   Pemeriksaan Fisik

Kepala: ......................................................................................................................................

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Muka:

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Ubun-ubun

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Mata : ............................................................................................................................

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Hidung : ............................................................................................................................

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Telinga : ............................................................................................................................

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Mulut : ............................................................................................................................

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Leher : ............................................................................................................................

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Dada : ............................................................................................................................

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Tali pusat

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Abdomen : ............................................................................................................................

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Punggung : ............................................................................................................................

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 Ekstermitas : ............................................................................................................................

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Genitalia : ............................................................................................................................

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Anus : ............................................................................................................................

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3.   Pemeriksaan Neurologis

Moro : ............................................................................................................................

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Rooting : ............................................................................................................................

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Sucking : ............................................................................................................................

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Swallowing: ............................................................................................................................

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Walking : ............................................................................................................................

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Graphs : ............................................................................................................................

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Tonicneck : ............................................................................................................................

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Burning : ............................................................................................................................

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4. Pemeriksaan Penunjang

a. Pemeriksaan Laboratorium
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b. Terapi

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6.DIAGNOSAKEPERAWATAN

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7.INTERVENSI

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8. IMPLEMENTASI

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9. EVALUASI

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