Buku Panduan Praktik Maternitas/Dept.Kepr.

Maternitas/Poltekkes/Nn/2022

ASUHAN KEPERAWATAN BAYI BARU LAHIR NORMAL

MENGGUNAKAN PENDEKATAN RAMONA T. MERCER

PENGKAJIAN
A. IDENTITAS BAYI
.......................................................................................................................................................................................................
.......................................................................................................................................................................................................
.....................................................................................................................................................................
B. FORMAL
1. Riwayat Persalinan Saat Ini
Tanggal.......................................
Kala I:
 Jam ........... WIB:
TD ............. mmHg, Nadi..........x/mNapas....... x/m, Suhu...........0C. His setiap10 menit .........
kali, lama .............dtk, DJJ ............. x/m, pembukaan.............. cm, portio tipis lunak,
ketuban......................., presentasi.........., hambatan di jalan lahir
....................................................................................................................................
 Jam ............ WIB:
TD ............. mmHg, Nadi...... x/m, Napas...... x/m, suhu........0C. His setiap 10 mnt...........kali,
lama ..........detik, DJJ ......... x/m.
Pembukaan lengkap, porsio tipis lunak, ketuban (......................).
....................................................................................................................................

Kala II:
Jam ............. WIB
Pembukaan lengkap, portio tipis lunak, kepala janin tampak di perineum, perineum
menegang, anus membuka dan ibu meneran.Kien di pimpin meneran saat his terasa, bayi
lahir pada pukul............... WIB, jenis kelamin perempuan, A/S ...................

Kala III:
Jam ............. WIB
TD ............... mmHg, Napas....... x/m, Nadi....... x/m, suhu.........0C.Oksitosin...... IU IM. Plasenta
lahir jam ............WIB lengkap dengan selaputnya, kontraksi uterus ............., teraba
keras.........jbp. Dilakukan pengecekan perineum dan portio, penjahitan luka
episiotomi.................................................................................
Kala IV:
Jam ...........................WIB
TD ............... mmHg, Napas............ x/m, Nadi...........x/m, Suhu.............0C,
Kontraksi uterus ..................HPP ..................................................................................

Praktik Keperawatan 4/PK4 Keperawatan Maternitas

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2. Bonding dan Attachment (Gray Skore) :

Skore Bonding Memandang Berkata Melakukan
sesuatu
1. Sangat ....................... ................................... ...............................
negatif, tidak ....................... ................................... ...............................
tepat
2. Agak negatif, ....................... ................................... .............................
tidak tepat ....................... ................................... .............................
....................... ................................... ...............................

3. Agak positif, ......................... ................................ ..............................

agak sesuai ........................ ................................... ..............................

4. Sangat positif, .................................... ............................................... ..........................................

sesuai .................................... ............................................... ..........................................
........ ........... ...........

3. Pengkajian Bayi
Nama : By. Ny .....................................................................................
Tempat Tgl. Lahir : Jakarta, ..................................., jam ................ WIB
Umur : .............. hari
Jenis kelamin : ..............................................
Kondisi Umum : ..........., reflek hisap (...........),
anak diberikan susu formula .................
suhu ............ C, Nadi:............. x/m, RR :........ x/m.
Riwayat kelahiran
- BB : ...................... gram
- Panjang badan : ............. cm
- Suhu : ...............0C
- Lingkar Kepala : ........... cm
- Lingkar dada : ................ cm
- Masalah dalam proses : ...........................................
kelahiran
- Lanugo : ....................................
- Vermix kaseosa : ........................................
- Mekonium :....................... jam setelah lahir
- Warna tubuh : ekstremitas..............., badan .................

Pemeriksaaan Reflek
- Reflek moro : ............................................
- Reflek menggegam : ...............................................
- Reflek menghisap : ...............................................
- Reflek tonik neck lemah :................................................
- Tonus otot/aktivitas : ...................................................
- Kekuatan menangis : .................................................

Pemeriksaan Fisik
a. Kepala
- Bentuk kepala : bentuk................., simetris....................
- Ubun-ubun : fontanel mayor ................. menutup
- Mata : Simetris, Mata............ membuka, reflek membuka
(.........), sclera mata ikterik (............), hiperemi (.........),
konjuctiva anemis ................., udem palpebra (.........),
Praktik Keperawatan 4/PK4 Keperawatan Maternitas
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pergerakan bola mata ........................ kesegala arah

: Terdapat rambut lanugo pada daun telinga, simetris

- Telinga (...........), bila dipegang lembut dan keduanya bersih/
tdk bersih
: Atresia ani (.........), septum tidak ada/ ada deviasi,
- Hidung kedua bersih/ tdk bersih............................................................
: Reflek menelan dan menghisap .........., labioskhisis
(.......), palatoskisis (........), cyanosis (................)
- Mulut

b. Punggung : ............................................................................
- Keadaan punggung
- Flesibelitas tulang : .............................................................................
punggung

c. Thorak
- Bentuk dada : .......................................................................
- Jenis pernapasan : .......................................................................
- Frekuensi napas ........................................................................

d. Abdomen
- Bentuk abdomen : .......................................................................
.........................................................................
- Bising usus : .......................................................................
e. Ekstremitas
- Jari kaki : ........................................................................
- Jari tangan : ........................................................................
- Pergerakan kaki : ........................................................................
- Pergerakan tangan : ........................................................................
: .........................................................................
- Garis telapak kaki
- Warna ekstremitas : .........................................................................
- Posisi ekstremitas : .........................................................................
f. Alat Reproduksi : .........................................................................
/Genitalia : .........................................................................
- laki-laki (penurunan
testis, ukuran) : .........................................................................
- perempuan (labia
minora, mayora, : .........................................................................
keluaran)
g. Fungsi Eliminasi : .........................................................................
- Fungsi miksi : .........................................................................
- Anus

Diagnosa Medis : ..........................................................................

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

Reflek primitif

No Reflek -
Reflek rooting
2 Reflek sucking
3 Reflek grasping
4 Reflekmoro
5 Reflekbabinski

Praktik Keperawatan 4/PK4 Keperawatan Maternitas

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Pengkajian Usia kematangan bayi berdasarkan New Ballard’s Score

Kematangan fisik

-1 0 1 2 3 4 5
Kulit Lengket Merah Merah Permukaan Daerah Retak lebih Seperti
transparan Transpar muda, mengelupa pucat, dalam kertas,
an licin, s dan ruam, retak – retak-
halus, vena retak, retak
vena kurang vena mengkerut
terlihat jarang
Lanugo Tidak ada Jarang Banyak Menipis Menghil Kebanyakan
ang tidak ada
Garis Jarak tumit Tumit Tanda Hanya garis Bebera Garis- garis
telapak jari kaki jari kaki merah anterior pa garis ditelapak
kaki 40-50 >50mm, sangat transversal di 2/3 kaki
mm=1 tidak ada sedikit melintang anterior
<40 mm = - garis
2
Payuda Tidak Samar – Areola Areola Areola Areola
ra kelihatan samar datar, muncul lebih penuh,
tidak sedikit, jelas, tonjolan 5-
ada tonjolan 1- tonjola 10 mm
tonjola 2mm n 3-4
n cm
Mata/ Kelopak Kelopak Daun Bentuk Bentuk, Tulang
telinga mata mata telinga lebih baik, sempur rawan,
tertutup terbuka, sedikit mudah na telinga tebal
Longgar:-1 daun meleng membalik membal dan kaku
Kuat : -2 telinga kung, ik
datar, lunak, seketik
masih rekoil a
terlipat memba
lik
lambat
Genital Scrotum Skrotum Testis Testis Testis Testis
Pria datar, kosong, ada turun, turun, menggantun
lembut rugae/lip diatas rugae rugae g, rugae
atan kanal, cukup bagus dalam
samar- rugae
samar jarang
Genital Klitoris Klitoris Klitoris Tonjolan Labia Labia mayor
wanita menonjol,la menonjol menon labia major mayor menutupikli
bia datar , labia jol, dan minor besar, toris dan
minor labia sama labia labia minor
kecil minor minork
membe ecil
sar

Kematangan Neuromuskuler
-1 0 1 2 3 4 5
Sikap NA Kedua Kedua Kedua Kedua bahu Kedua bahu NA
pergelangan pergelangan bahu panggul dan dan kedua
tangan, tangan panggul kedua kaki kaki
lengan, bengkok, dan dan bengkok bengkok
panggul dan kedua kaki kedua tapi sampai dan
kedua kaki agak bengkok kaki 900 menutup ke
lurus bengkok arah badan
tapi tidak
sampai

Praktik Keperawatan 4/PK4 Keperawatan Maternitas

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900

Sudut Siku > 900 900 600 450 300 00 NA

Kelenturan NA 1800 140-1800 110-1400 90-1100 <900 NA
Lengan
Sudut 1800 1600 1400 1200 1100 900 <900
Poplitea
Tanda Siku Siku sampai Siku sampai Siku yang Siku sampai Siku sampai
Selampang melebi garis axilla garis berada garis axilla garis axilla
hi garis yang midklavikula digaris Siku tidak
axilla berlawanan yang tengah sampai pada
yang berlawanan tubuh garis axilla
berlaw
anan
Tumit ke Kaki Kaki lurus, Lutut agak Lutut Lutut Lutut
telinga lurus, jari-jari bengkok, bengkok, bengkok, bengkok,
tumit sampai dagu tumit sampai tumit sampai 900, tumit
sampai 1400 dari sampai tumit sampai 450
telinga bidang datar 1200 dari sampai 900 dari bidang
bidang dari bidang datar
datar datar

Perhitungan Kematangan

SKOR MINGGU
-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44

Pola Fungsi Kesehatan bayi

1. Nutrisi dan metabolisme : .....................................................................................
2. Eliminasi : ......................................................................................
3. Istirahat dan tidur : .......................................................................................
4. Aktifitas dan latihan : .......................................................................................
5. Lainnya : ......................................................................................

4. AspekPsikososialIbu
a. Empatisensitivitasterhadapisyaratbayi:
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
b. Konsep Diri
o Identitas diri: ..................................................................................................................................................
...............................................................................................................................................................................

Praktik Keperawatan 4/PK4 Keperawatan Maternitas

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o Harga diri: ........................................................................................................................................................

...............................................................................................................................................................................
o Peran: ................................................................................................................................................................
...........................................................................................................................
o Gambaran diri: ..................................................................................................
...........................................................................................................................
o Citra Tubuh:........................................................................................................
..............................................................................................................................
c. Kesesuaian antara harapan dan kenyataan:
.......................................................................................................................................................................................
.................................................................................
d. Sikap ibu terhadap persalinan dan merawat bayi:
.......................................................................................................................................................................................
.................................................................................
e. Pengalaman melahirkan:
.......................................................................................................................................................................................
.......................................................................
f. Kecemasan: .....................................................................................................................
g. Depresi: ...........................................................................................................................
h. Konflik peran: ................................................................................................................
....................................................................................................................................
i. Fleksibilitas
No Kegiatan Ibu Ya Tidak
1. Apakah ibu menyentuh bayi
2. Apakah ibu mulai menyusui bayi
3. Apakah ibu merawat tali pusat bayi
4. Apakah ibu mengganti popok bayi
5. Apakah ibu memandikan bayi
6. Apakah ibu tampak bisa menenangkan bayi
7. Apakah ibu mulai menggendong bayi

5. Peran Ayah Selama dan setelah Kelahiran

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

C. INFORMAL
1. Orang yang terlibat dalam perawatan bayi:
..........................................................................................................................................
2. Peran dalam perawatan bayi:
..........................................................................................................................................
3. Pengalaman dalam perawatan bayi:
.........................................................................................................................................

Praktik Keperawatan 4/PK4 Keperawatan Maternitas

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4. Harapan untuk perawatan bayi:

.........................................................................................................................................
DIAGNOSA KEPERAWATAN

1. .........................................................................................................................................
2. ........................................................................................................................................
3. ........................................................................................................................................

PRESEPTEE,

(..................................................................)

Praktik Keperawatan 4/PK4 Keperawatan Maternitas

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Buku Panduan Praktik Maternitas/Dept.Kepr.Maternitas/Poltekkes/Nn/2022

INTERVENSI, IMPLEMENTASI DAN EVALUASI ASUHAN KEPERAWATAN

DIAGNOSA TUJUAN DAN IMPLEMENTASI
KEPERAWATAN KRITERIA HASIL INTERVENSI JAM TINDAKAN
EVALUASI
(SDKI) (SLKI) (SIKI)

Praktik Keperawatan 4/PK4 Keperawatan Maternitas

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