S/ KULIT: _____________________________ TTD

KUKU: _____________________________ DPJP

KELAIANAN BAWAAN:
___________________________________

BB LAHIR : ________________________
PB LAHIR : ________________________
LK LAHIR : ________________________
LD LAHIR : ________________________
LP LAHIR : ________________________
O/ PEMERIKSAAN FISIK
STATUS PRESENT APGAR SCORE
Aktivitas / Tangis : 1’ 5’ 10’
Nadi : Appearance
Respirasi : Pulse
Suhu : Grimace
SpO2 : Activity
STATUS GENERAL Respiration
KEPALA Total
- UUB : DOWN SCORE
- UUK : 0 1 2
- Sefalhematom : ya tidak RR <60x/m 60-80x/m >80x/m
- Caput Succadeneum : ya tidak Sianosis - hilang dgn O2 Menetap
- Lain-lain : Retraksi - Ringan Berat
MATA Air Entry Good Mild Decrease No airentry
Kongjungtiva : Pucat: ______ Ikterik: ______ Grunting - Audible Audible with ear
Pupil : Isokor: ______ Reflek: ______ With stetoskop
THT Total:_________________________________
Nafas cuping hidung 0-4 : Distress nafas ringan (O2 nasal / headbox)
Sianosis 4-7 : Distress nafas berat ( Nasal CPAP)
Lain-lain: _________________________ >7 : Distress nafas berat (ancaman gagal nafas)
MULUT: _____________________________ A/ DIAGNOSIS KERJA / BANDING
LEHER : _____________________________
THORAX
Bentuk
P/ INSTRUKSI TINDAKAN & TERAPI
Simetris
Asimetris
Areola Mamae : _______________________
Paru : _______________________
Jantung : _______________________
ABDOMEN
Distensi : ___________ Bising Usus: __________
Vena : ________________________________
Hepar : _____________ Lien: ______________
Tali Pusat : Segar Layu
GENITALIA EKSTERNA
___________________________________
ANUS: _____________________________
EKSTREMITAS
Plantar Crease
1/3 ant 2/3 ant >2/3 ant

ASSESMEN AWAL BAYI BARU LAHIR Nama : ____________________________

No Rekam medis : ____________________________
Tanggal lahir : ____________________________