PROGRAM PROFESI NERS FAKULTAS ILMU KEPERAWATAN UNIVERSITAS MUHAMMADIVAH JAKARTA. JI. Cempaka Putih Tengah | No. | Jakarta Pusat Telp/Fax:: (021) 42802202 PENGKAJIAN BAYI Nama Bayi PAWS. Tanggal dirawat t Lares -lalel 7 Alamat Jenis kelamin Tel lahir/usia Nama orang tua Pendidikan ayabyibu : S\ Pekerjaan ayah/ibu Usia ayah/ibu Diagnosa medis 1 BAL d2 , Deonaus Inpesi / Levee sito sit Riwayat bayi Apgar score Usia gestasi IBHS. Panjang cadan 4. Berat badan Komplikasi persalinan : B Tidak ada ( ) a. Aspirasimekonium . Denyut jantung janin abnormal ( ) S c. Masalah lain d. Prolaps tali pusat/lilitan tali pusat Ketuban pecah dini (7; berapa jam = e. Riwayat ibu Usia Gravida Partus Abortus ao I Dv O Praktik Profesi Keperawatan Anak | FIK-UMJ 54Jenis persalinan © Pervaginam ) \Keuban © SectioCesaria (4) ; Alasan Recaln din. (sum Usk Ketutoantoa) Komplikasi kehamilan © Tidakada (+) Ada ( ) . Perawatan Antenatal ( ) © Ruptur plasenta / plasenta previa ( ~) . Preeklamsia / toxemia (_ ) © Suspect sepsis ( Yj © Persalinan premature/post matur (_ ) © Masalah lain Pengkajian Fisik Neonatus Instruksi : Beri tanda cek ( (1) pada istilah yang tepat/sesual dengan data- data di bawah ini. Gambarkan semua temuan abnormal secara objektif, gunakan kolom data tambahan bila perlu, 1. Reflek : Moro (Vj menggenggam 1 mengisap — ({~ 2. Tonus/aktifitas a. AktiF Letargi [| kejang fl b. Menangis keras [\J lemah [ ] melengking [ ] sulit menangis [ ] 3. Kepala/leher a. Fontanel anterior lunak [1 tegas U1 Datar [ ] menonjol { } — cekung [ ] terpish [ ] — menjauh [ ] b. Sutura sagitalis tepat oy simeteris (Mf — asimetris [_] ¢. Gambaran wajah Praktik Profesi Keperawatan Anak | FIK-UM] 551 Cephalohematoma { | 4. Molding caput succedaneum 4. Mata: Bersih f sekrest =) s. Hr a.Telings (Wf normal WA abnormal ( ] b. Midung ff 6. Abdomen a. Lunak eae tegas [ 1 datar my kembung [ ] b._ Lingkaran perut... om 6 Uver aeons Kurang 2em [ ] lebih 2em [ ] 7. Toraks a. simetris. (Y asimetis (J b. Retiyksi : derajat 1] — derajat 2 derajat 3 [ ] . Klavikula normal [ abnormal [ } 8. Paru-paru 2. Suaranafaskanan kiisama (M{—Asimetvis (1 b. Bunyinafas disemua lapang paru: terdengar [\{~ _ tidak terdengar [ ] menurun [ ] c. Suaranafasbersh (“{ ronehi { } les []— sekresi 1 d. Respirasi spontan f/falat bantu : 9. Jantung a. Bunyi Normal Sinus Rhythm (NSR) [ ] frekuensi : b. Murmur [] pm ] c. Waktu pengisian kapiler : 10.Ekstremitas 2. Gerakan bebas (ROM terbatas [ ] tidak terkaji [ b. Nadi perifer Keras Lemah Tidak Ada Brakial Kanan Brakial kiri Femoral kanan J Femoral kiri v Praktik Profesi Keperawatan Anak | FIK-UMJ 15611, Umbilikus Normal mM Drainase [] Jumiah pembuluh darah [| 12. Ekstremitas atas:normal (Vf abnormal [_ J, sebutkan: 13. Ekstremitas bawah normal 4 abnormal [ ] tidakterkaji { 1 14. Genital Perempuan normal [ ] laki-laki normal tM abnormal [1 15, Anus +: paten +4 Imperforata v1 16. Spinal : normal Vf abnormal ul 17. Kulit a. warna : pink (Mf pucat {1} { ] seluruhtubuh [ ] jaundice [ ] Sianosis padkuku [ ] sirkumoral [ ] Periorbital b. Kemerahan(rash) [ ] ¢. Tanda lahir «.. 18. Suhu a. Lingkungan: Penghangat radian [ ] Pengaturan suhu [] Inkabator 4 suhuruang = [ ] boks terbuka ial 2.6... b. Suhu kulit ft an anneumtan Anal | RIK-UMI 57RIWAYAT SOSIAL Struktur keluarga ( genogram tiga genera) Ch-& Kelerangan: we) D+Layi -tatel O> Peremeran @ eMennrgya fey = [ctien - an dan Rdak Me tou Klien Rereima all MeO EG? vo Giannan lawn weracrat (od Antisipasi vs pengalaman nyata kelahiran: . . Budaya : Jota, . ‘Suku © Agama © Bahasa utama (ndonesvar © Perencanaan makanan bayi Ast . Masalah sasial yang penting © Hubungan orang tua dan bayi [ BU TINGKAH LAKU AYAH | v Menyentuh v Memeluk © Berbicara vv Berkunjung v Vv Memanggil nama Kontak mata Praktik Profesi Keperawatan Anak | FIK-UM] 58# Orang terdekat yang dapat dihubung! mt / Keluag ‘# Orangtua berespon terhadap penyatit bya wis respon - Seta mengetahui hasiL Lalo U9 diveritary ach dover Kata leurest GAREGReS ALONO TO pats dan cli peri NFUGEA tidak [J mae svt) Respon © Riwayat anaklain: T\clayje coda Riwayat Imunisasl Jenis kelamin anak Riwayat persalinan Data Tambahan ( pemeriksaan diagnostic ) Tangga\ Poritesa = 30-10-2072. Pemeriiesaan, { Hast Dormar | Intexgreaast > Remagioloin 19.4 V5, Q-14 Arnggi - Leutosit 3\.\00 4230 -9,030 | kwggi Praktik Profesi Keperawatan Anak | FIK-UMJ 59Resume hasil pengkajian ( riwayat masuk hingga saat ini ) _ BBW.V kanggal Zo okWber 2022. Rahirecin . 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