A.

FORMAT PENGKAJIAN
PROGRAM PENDIDIKAN SARJANA
KEPERAWATAN
FAKULTAS ILMU-ILMU KESEHATAN
KEPERAWATAN BAYI BARU LAHIR
UNIVERSITAS NUSA NIPA
MAUMERE
2022

Tanggal MRS :
No. reg ( CM ) : Diagnosa medis :
Pengkajian tanggal : Jam pengkajian :

I. DATA UMUM
1. IDENTITAS BAYI
1. Nama bayi : .......................................................................................................
2. Jam lahir : .......................................................................................................
3. Jeniskelamin : .......................................................................................................
4. Berat badan lahir : .......................................................................................................
5. Panjang Badan : .......................................................................................................
6. Lingkar kepala : .......................................................................................................
7. Lingkar dada : .......................................................................................................
8. Lingkar lengan : .......................................................................................................
2. IDENTITAS IBU / AYAH

 IBU  AYAH

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

Umur : ............................. Umur : .............................
Pekerjaan : ............................. Pekerjaan : .............................
Suku/bangsa : ............................. Suku/bangsa : .............................
Agama : ............................. Agama : .............................
Alamat : ............................. Alamat : .............................
Status perkawinan : ............................. Status perkawinan : .............................

II. Keluhan Utama Saat Masuk Rumah Sakit

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III. Riwayat Penyakit Sekarang

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III. RIWAYAT PERSALINAN SEKARANG : ( ) Gravida ( ) Partus ( ) Abortus
1. Pre Natal
JumlahKunjungan : ...................................................................................
Pendkes yang didapat : ...................................................................................
Penyakit/ Komplikasi saat kehamilan : ...................................................................................
Berat Badan Sebelum Hamil : ……………………………………...........................
Berat Badan Selama Hamil :………………………………………………………
Kenaikan BB selama Kehamilan :……………………………………………………..

Obat-obatan yang didapat : ...................................................................................

Imunisasi : ...................................................................................
Riwayat Hospitalisasi : ...................................................................................
Golongan Darah Ibu : ...................................................................................

2. NATAL
Awal Persalinan : G ............... P ................... A.........................
Lama Persalinan :
Kala I ……………………….jam; ……………………….menit
Kala II …………………….. jam; ………………………..menit
Kala III ……………………..jam; ………………………..menit
Keadaan air ketuban : ...................................................................................
Waktu pecahnya ketuban : ...................................................................................
Persalinan : ...................................................................................
Lilitan tali pusat : ...................................................................................
Ditolong oleh : ...................................................................................
Kala IV …………………………jam; …………………..menit
Komplikasi Persalinan : ...................................................................................
Terapi Yang diBerikan : ...................................................................................
Cara Melahirkan : Pervaginam / Caecar /Vakum / Lainnya :...............................
Tempat Persalinan : ...................................................................................

3. POST NATAL
BB Lahir : ............................ gram
PB : ...................................................................................
Lingkar Kepala : ...................................................................................
Lingkar Dada : ...................................................................................
Lingkar Abdomen : ...................................................................................
Usaha Napas : dengan bantuan / Tanpa bantuan
 APGAR SCORE

MENIT
NO ASPEK PENILAIAN 0 I V
0 1 2 0 1 2 0 1 2
1 Frekuensi jantung
2 Usaha napas
3 Tonus otot
4 Warna kulit
5 Reaksi terhadap rangsang
Jumlah
Catatan :beritanda (  ) pada menit pertama (1 ) dan tandaa ( X ) pada menit ke lima ( V )
Kesimpulan : …………………………………………………………………………………..

IV. RIWAYAT KELUARGA

Genogram:

Ket.:
V. RIWAYAT SOSIAL

1. Hubungan Orang Tua dan Bayi

Menyentuh : ................................................................................................................................

Memeluk : ................................................................................................................................

Berbicara : ................................................................................................................................

Berkunjung : ................................................................................................................................

Kontak Mata : ................................................................................................................................

2. Hubungan Orang Tuadan Anak Lain : ........................................................................................

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Kondisi Lingkungan Rumah : .........................................................................................

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Problem Sosial yang penting : .........................................................................................

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Kurangnya sistem pendukung social : .........................................................................................

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Perbedaan Bahasa : .........................................................................................

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Riwayat Ibu Perokok berat : .........................................................................................

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Status ekonomi : .........................................................................................

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Lain- lain : ........................................................................................

VI. RIWAYAT KESEHATAN SAAT INI

1. DiagnosaMedis : ...................................................................................................................

2. Status Nutrisi : ...................................................................................................................

3. Status Cairan : ...................................................................................................................

4. Aktivitas : .................................................................................................................
 5. TERAPI

Cara
Tg N Dosis KontraIndikas
Terapi Pemberia Indikasi
L o (KandunganObat) i
n
 6. PemeriksaanPenunjang

N Satua
Tanggal Pemeriksaan Kriteria HasilPemeriksaan Nilai Normal
o n
VII. PEMERIKSAAN FISIK
1. KEPALA
a. Ubun – ubun besar : ............................................................................................................
b. Ubun – ubun kecil : ............................................................................................................
c. Caput succedaneum : ............................................................................................................
d. Bentuk kepala : ............................................................................................................
e. Cepal hematoma : ............................................................................................................
f. Suturasagitalis : ............................................................................................................
g. Luka :ada / tidak, .........................................................................................
h. Keadaan rambut :............................................................................................................
i. Keadaan kulit kepala :............................................................................................................
j. Refleks tonic neck :………………………………………………………………………
Reaksi :………………………………………………………………………

2. MATA
a. Kesimetrisan : ............................................................................................................
b. Strabismus : ............................................................................................................
c. Bola mata : ............................................................................................................
 Jarakantara bola mata : ....................................................................................................
 Ukuran bola mata : ....................................................................................................
 Lesi :Ada / Tidak
 Warna : ....................................................................................................
 Jaundice : Ada / Tidak
 Purulen : Ada / Tidak
 Gerakan bola mata : ...................................................................................................
d. Alismata :
 Jumlah : ....................................................................................................
 Bentuk : ....................................................................................................
e. Sclera : Putih / Pucat / Merah
f. Refleks Burning :…………………………………………………………………
Reaksi :…………………………………………………………………
3. HIDUNG
 Bentuk : ....................................................................................................
 Letak :....................................................................................................
 Cupinghidung :....................................................................................................
 Mukosa :....................................................................................................
4. MULUT
a. Keadaanmulut : ....................................................................................................
 Bentuk :....................................................................................................
 Warna :....................................................................................................
  Gerakan :....................................................................................................
b. Rongga mulut :....................................................................................................
 Lidah :....................................................................................................
 Saliva :....................................................................................................
 Warna :....................................................................................................
 Gigi :....................................................................................................
 Rumusan gigi : ....................................................................................................
c. Palatum :....................................................................................................
d. Refleks : ....................................................................................................
 Rooting :.....................................................................................................
Reaksi :…………………………………………………………………
 Sucking :....................................................................................................
Reaksi :…………………………………………………………………
 Swallowing :………………………………………………………………….
Reaksi :………………………………………………………………….
5. TELINGA
 Bentuk :....................................................................................................
 Kedudukan :....................................................................................................
 Saluran pendengaran : ....................................................................................................
 Cairan : ....................................................................................................
6. DADA
a. Bentuk : ....................................................................................................
b. Clavikula tulang iga : ....................................................................................................
c. Putting susu :....................................................................................................
 Ukuran : ....................................................................................................
 Letak : ....................................................................................................
 Jumlah : ....................................................................................................
 Jaringan susu :....................................................................................................
 Ekskresi susu : ....................................................................................................
d. Gerakan respirasi : .....................................................................................................
 Rales :Ada / Tidak, .................................................................................
 Ronchi :Ada / Tidak, .................................................................................
 Wheezing :Ada / Tidak, .................................................................................
e. Denyutjantung : ......................................................................................................
 Murmur :Ada / Tidak, ..................................................................................
 Aritmia :Teratur / TidakTeratur ................................................................
7. ABDOMEN
a. Bentuk : .................................................................................................
b. Tali pusar :.................................................................................................
 Perdarahan sekitar tali pusat : Ada / Tidak, ..................................................................
 Arteri / vena : Lengkap / Tidak, ..........................................................
 Gastroskizis : Ada / Tidak, ..................................................................
  Berakmekonium : Ada / Tidak, ..................................................................
c. Bisingusus : .................................................................................................
d. Warna kulit perut : .................................................................................................
e. Gerakan respirasi diafragma : .................................................................................................
8. PUNGGUNG,PANGGUL,BOKONG
a. Tulang belakang : .................................................................................................
b. Bahu/scapula : .................................................................................................
c. Crista iliaka : .................................................................................................
d. Dasar tulang belakang : .................................................................................................
e. Area piidinea : .................................................................................................
f. Reflex membungkuk : .................................................................................................
g. Lipatan bokong : .................................................................................................
h. Warna kulit bokong : .................................................................................................
9. GENITALIA
LAKI – LAKI
a. Meatus : ..............................................................................................................
b. Preposium : ..............................................................................................................
c. Scrotum : ..............................................................................................................
d. Rugae : ..............................................................................................................
PEREMPUAN
a. Labia mayora : ..............................................................................................................
b. Labia minora : ..............................................................................................................
c. Klitoris : ..............................................................................................................
d. Pengeluaran vagina : ..............................................................................................................
e. Meatus urinarius : ..............................................................................................................
10. EKSTREMITAS
Tangan ;
a. Tingkat fleksi : ......................................................................................................
b. Tingkat gerakan : ......................................................................................................
c. Kesimetrisan : ......................................................................................................
d. Tonus otot : ......................................................................................................
e. Clacvicula : ......................................................................................................
f. Lengan : ......................................................................................................
g. Jumlah jari :......................................................................................................
h. Tulang sendi : ......................................................................................................
 Bahu : ......................................................................................................
 Siku :......................................................................................................
 Pergelangan tangan :......................................................................................................
 Jari – jari :......................................................................................................
i. Reflex menggenggam :......................................................................................................
Reaksi :………………………………………………………………….
Kaki :
 a. Pergerakan : Baik / Kaku/ Lemah
b. Jumlahjari kaki : ......................................................................................................
c. Lipatan gluteal mayor : Rata / Tidak Rata
d. Warna kuku : ......................................................................................................
e. Reflex babinsky : ......................................................................................................
Reaksi :…………………………………………………………………..
f. Refleks Moro :…………………………………………………………………..
Reaksi :………………………………………………………………….
g. RefleksWalking/Step :…………………………………………………………………..
Reaksi :…………………………………………………………………..
11. ANUS
Kelainan :ada / tidak, .............................................................................................................
12. VERNIX & LANUGO
a. Vernix : ...............................................................................................................
 Warna : ...............................................................................................................
 Bau : ...............................................................................................................
b. Lanugo : ...............................................................................................................
13. NUTRISI
1. Minuman yang diberikan : ASI / PASI
2. Pemberian :......................................................................................................
14. ELIMINASI
1. Mekonium
a. Konsistensi : ...............................................................................................................
b. Warna : ...............................................................................................................
c. Bau : ...............................................................................................................
2. BAK
a. Frekuensi : ...............................................................................................................
b. Konsistensi : ...............................................................................................................
c. Warna : ...............................................................................................................
d. Bau : ...............................................................................................................
15. ISTIRAHAT TIDUR
1. Sehari : …………………………..jam
2. Keadaanwaktutidur : .................................................................................................................
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16. TANDA – TANDA VITAL
1. KeadaanUmum : ...................................................................................................................
2. Suhu :……….0C
3. Nadi :………..x/ menit
4. Respirasi :………..x/menit
5. WarnaKulit : .....................................................................................................................
 17. Ballard Score :

 Penilaian Maturitas Neuromuskuler :………………………………………………………..

 Penilaian Maturitas Fisik :……………………………………………………………………
 Jumlah Ballard Score :……………………………………………………………………….

18. Pengkajian Derajat Ikterik Menurut KRAMER :(khusus bayi dengan kasus ikterik neonatorum):

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Kesimpulan:………………………………………………………………………………………..

......................., ………………… 2021 Mengetahui,

Pengkaji, CI Ruang ...................................

(______________________________) ( ________________________ )
 B. KLASIFIKASI DATA :

Hari / Tanggal : ……………………………...........................................................................

Nama Klien/ Usia : …………………………......./ .....................................................................
Diagnosa Medis : ……………………………...........................................................................

DATA SUBYEKTIF :
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DATA OBYEKTIF : (Termasuk Hasil Pemeriksaan Fisik, Monitoring, dan Pemeriksaan Penunjang)
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C. ANALISA DATA :

Hari / Tanggal : ……………………………...........................................................................

Nama Klien/ Usia : …………………………......./ .....................................................................
Diagnosa Medis : ……………………………...........................................................................
(minimal 3 diagnosa)
No Data Etiologi Problem (NANDA)
 D. DIAGNOSA KEPERAWATAN :

Hari / Tanggal : ……………………………...........................................................................

Nama Klien/ Usia : …………………………......./ .....................................................................
Diagnosa Medis : ……………………………...........................................................................

PRIORITAS MASALAH KEPERAWATAN :

1. .............................................................................................................................................

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E. PATOFLOW KASUS :
 Contoh Format
SALIN di
F. RENCANA KEPERAWATAN lembarbagiantengahDouble Folio
DEPARTEMEN ........................................................... Bergaris
NAMA KLIEN : .................................................................................................................................... NAMA MAHASISWA : .............................................................................
NIRM : .................................................................................................................................... PROGRAM : .............................................................................
DIAGNOSA MEDIS : .................................................................................................................................... INSITITUSI : ..............................................................................
BANGSAL / TEMPAT : ....................................................................................................................................

KONFIRMASI DATA TUJUAN DAN RENCANA IMPLEMENTASI PARAF

DIAGNOSA AKTUAL /
No TGL RESIKO / PK / KRITERIA HASIL KEPERAWATAN (NIC) EVALUASI
KEPERAWATAN (NANDA)
WELLNESS (NOC) DAN RASIONAL Tgl / PELAKSANAAN Mahasiswa CI / CT
REKAM MEDIK PASIEN
Jam
1 ....
R/ ....
Pemeriksaan DS : Catatlah implementasi S:
2. ...
Penunjang: yang telah dilakukan dan O:
R/ ....
 Lab, kegiatan keperawatan A:
Dst..
Rontgen, serta medis 1x 24 jam P:
DO : (Berdasarkan ONEC,
Ct Scan, selama minimal 3 hari
 Obser- yaitu :
MRI, dsb. untuk setiap diagnosa
vasi  Observation
keperawatan
 PemFis (Observasi)
Monitoring  Nursing (Tindakan
Mandiri Perawat)
 Education
(Pendidikan
Kesehatan)
 Collaboration
(Kolaborasi Medis,
Paramedis, dan
Keluarga)

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