Form RM 3.27 Rev.

0/2023

No. RM
PENGKAJIAN AWAL Nama
BAYI BARU LAHIR Jenis Kelamin
Tanggal Lahir
(mohon diisi atau tempelkan stiker)
Ruang / Kelas : .............................................

PENGKAJIAN PERAWAT
(Dilengkapi dalam waktu 24 jam pertama setelah bayi lahir / bayi masuk ruang rawat)
Nama Bayi Kelamin Tgl. Lahir Jam Lahir No. Register Bayi

Nama Ibu Nama Ayah Ruangan Ibu No. Register Ibu

Cara Persalinan :

Keadaan bayi waktu dilahirkan :

Status Sosial, Ekonomi, Spiritual Suku / Budaya, Nilai Kepercayaan

1 Status psikologis : Cemas  Takut  Marah  Sedih  Depresi  Lain-lain.................
2 Status sosial : Hubungan pasien dengan anggota keluarga :  Tidak baik  Baik
3 Status ekonomi : Pekerjaan :  PNS  Swasta  IRT  Pelajar  Lainnya..........
Tinggal bersama : Orang tua  Rumah sendiri  Ngontrak  Lainnya...................
4 Spiritual (Agama) : Islam  Protestan  Katholik  Hindu  Budha  Konghucu  Lainnya.....
5 Suku / Budaya : Betawi  Jawa  Sunda  Lainnya..................................
6 Nilai - nilai kepercayaan pasien / keluarga :  Tidak Ada  Ada, ...............

Riwayat Ibu
1. Riwayat Obstetrik :G P A Usia Gestasi : mg
2. Pernah dirawat :  Tidak  Ya Indikasi Rawat : ...................................
3. Status Gizi Ibu :  Baik  Buruk  Lain - lain : ....................................
4. Obat - obatan yang dikonsumsi selama kehamilan :  Tidak Ada  Ada, Jenis .........................................................
5. Kebiasaan Ibu :  Merokok  Minum Jamu  Minuman Beralkohol  Dll .............................................
6. Riwayat Persalinan :  SC  Spontan Kepala / Bokong  VACUM  FORCEP
Ketuban :  Jernih  Hijau encer / kental  Meconium  Darah  Putih Keruh  Lain - lain : ......................
Volume :  Normal  Oligohidramnion  Polihidramnion, APGAR SCORE : ...................
7. Antropometri BBL : BB gr, PB cm, LK cm, LD cm, LP : cm
8. Riwayat Penyakit Ibu :  Tidak Ada  Ada  Diabetes  Kanker  Asma  Hipertensi  Jantung
 Lain-lain : ....................................
9. Riwayat Alergi Obat / Makanan :  Tidak Ada  Ada, sebutkan ...................................................
SKALA NIPS (NEONATAL INFANT PAIN SCALE)
SKOR
No. PEMERIKSAAN
1 2 NILAI
1. Ekspresi Wajah Santai / Tenang Meringis
2. Tangisan Tidak Menangis Merengek Menangis Keras
3. Pola Pernafasan Santai / Tenang Berubah
4. Lengan Santai / Tenang Fleksi / Ekstensi
5. Kaki Santai / Tenang Fleksi / Ekstensi
6. Keadaan Bayi Tidur / Bangun Rewel
TOTAL SKOR
Skala Nyeri : 1 - 3 : Nyeri Ringan 4 - 5 : Nyeri Sedang 6 - 7 : Nyeri Berat

PENGKAJIAN RESIKO JATUH NEONATUS / BAYI BARU LAHIR

Semua Neonatus dikategorikan beresiko jatuh

SKRINING GIZI
 ASI  PASI  Lain - lain, ....................................

Pemeriksaan Fisik Sekarang

 Form RM 3.27 Rev.0/2023

Keadaan umum : ............................................................................................................................................

Tanda - tanda vital Suhu : ........... ○C Nadi : .........x/m RR : ..........x/m Tekanan Darah : ............mmhg
Saturasi O₂ : ..................................................
Antropometri BBL : .......... gr BBS ............ gr Panjang Badan : ...........cm Lingkar Kepala : ..........cm
Lingkar dada : ..................cm Lingkar Perut : .................. cm
APGAR SCORE 1 menit 5 menit
Warna kulit
Reflek
Denyut jantung
Tonus
Usaha bernafas
Jumlah score
URAIAN
Kepala  Normal  Benjolan  Luka  ………………………………………..
Mata  Normal Pupil  Isokor  Anisokor  ………………….
THT  Normal  Luka  Sumbatan  ………………………………….
Mulut  Normal  luka  Benjolan  ………………………………….
Leher  Normal  luka  Benjolan  ………………………………….
Thorak  Normal  luka  Benjolan  ………………………………….
Abdomen  Normal  Asistes  tegang  ………………………………….
Urogenital  Normal  Tidak Normal  …………………………………..
Ekstermitas  Normal Atas  Kuat  Lemah Bawah  Kuat  Lemah
Kulit  Normal Turgor  Baik  Dehidrasi Luka  ya  Tidak
Jantung  Normal Nyeri dada  Ya  Tidak Bunyi jantung  Murmur  Gallop
Kebutuhan Edukasi
Edukasi diberikan kepada :  Pasien  Keluarga (Hubungan dengan pasien ...............................................................)
Hambatan dalam pembelajarannya :  Tidak ada  Ada , sebutkan hambatannya .............................................................
Dibutuhkan penerjemah :  Tidak  Ya, sebutkan ..............................
Bahasa sehari-hari :  Indonesia  Daerah, ..............................
Kebutuhan edukasi :
 Proses penyakit  Pengobatan dan tindakan  Diet dan Nutrisi  Rehabilitasi  Manajemen Nyeri
 Lainnya ...........................................................
Masalah Keperawatan
 Hipertermi  Nyeri akut/kronis  Bersihkan jalan nafas
Pola nafas tidak efektif  Resiko infeksi  Gangguan pertukaran gas
Ketidakseimbangan nutrisi kurang dari kebutuhan  Kejang berulang  Defisit volume cairan
Gangguan mobilitas fisik  .............................................................
 Bagian 7 : Diagnosa Keperawatan
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 Rencana Asuhan Keperawatan  Intervensi Asuhan Keperawatan
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Jakarta, Tanggal........................ Jam ............... Tanggal........................... Jam ...............

Perawat yang melakukan pengkajian Perawat yang melengkapi pengkajian

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Nama jelas & Tanda tangan Nama jelas & Tanda tangan

PENGKAJIAN DOKTER
S (Anamnesa)
 Form RM 3.27 Rev.0/2023

Keluhan saat ini : ....................................................................................................................................................

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Riwayat kesehatan pasien : .....................................................................................................................................
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O (Obyektif) : Pemeriksaan Umum : G C S : E ....................M....................V....................Total : ............
TD ......................... mmHg, Suhu ......................... C, Nadi ......................... x/m, RR..................................x/m
Pemeriksaan Fisik :
Kepala : ........................................
Leher : ........................................
Thorax : ........................................
Abdomen : ........................................
Pemeriksaan Khusus :
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Pengkajian risiko nutrisional : Stunting : Ya Tidak
Wasting : Ya Tidak
Pemeriksaan Penunjang :
Lab : ........................................
USG : ........................................
Lainnya : ........................................
A (Diagnosa) Medis
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P (Penatalaksanaan)
Terapi : ...............................................................................................................................................................
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Monitoring : ...............................................................................................................................................................
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Diit : ................................................................................................................................................................
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Discharge Planning : .............................................................................................
Jakarta, Tanggal ................................. Jam .............
DPJP

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Nama Jelas & tanda tangan