FORMAT PENGKAJIAN

RUANG NEONATAL INTENSIVE CARE UNIT (NICU)

PROGRAM PROFESI NERS FAKULTAS ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH GORONTALO

A. IDENTITAS
Inisial Nama Ibu Bayi : ___________________________________________
Tanggal /jam pengkajian : ___________________________________________
Nama Ayah : ___________________________________________
Pekerjaan : ___________________________________________
Alamat : ___________________________________________

B. KEADAAN BAYI BARU LAHIR

Lahir tanggal : ___________________ Jam : __________
Jenis Kelamin : ___________________________________________
Riwayat Persalinan : ___________________________________________
Berat badan Lahir :_______kg
Panjang badan : _______cm
HR : _______x/menit
Pernapasan : _______x/menit
Suhu : _______0C

C. Riwayat Nilai Apgar

NO. TANDA 0 1 2 JUMLAH
1. Frekuensi □ Tidak Ada □ < 100 □ > 100
Jantung
2. Usaha Nafas □ Tidak Ada □ Lambat □ Menangis
Kuat
3. Tonus Otot □ Lumpuh □ Ekstremitas □ Gerakan
Refleks Aktif
Sedikit
4. Refleks □ Tidak □ Gerakan □ Reaksi
Beraksi Sedikit Melawan
5. Warna Kulit □ Biru Pucat □ Tubuh □ Kemerahan
Kemerahan,
Tangan &
Kaki Biru
Ket : penilaian menitke1 = ___________ penilaian menit ke 5= ____________
Tindakan resusitasi : ___________________________________________
Tali pusat : ___________________________________________

ProgramStudiProfesiNersJurusanKeperawatanFIKESUMG
 D. PENGKAJIAN FISIK
Umur : __________________________________________________
Berat badan : ______gr
Panjang : ______cm
Antropometri
BBL : ______gr BB sekarang : ______gr
Panjang Badan : ______cm
Lingkar Kepala : ______cm
Lingkar Paha : ______cm
Lingkar Dada : ______cm
LILA : ______cm
Tanda – Tanda Vital
Frekuensi Nadi : ______x/menit
Pernapasan : ______x/menit
Suhu : ______0C
KEPALA & LEHER
1) Bentuk :__________________________________________________
2) Ubun – ubun :__________________________________________________
3) Mata : __________________________________________________
4) Telinga :__________________________________________________
5) Mulut : __________________________________________________
6) Hidung : __________________________________________________
7) Leher : __________________________________________________
TUBUH
1) Warna :__________________________________________________
2) Pergerakan :__________________________________________________
3) Dada :__________________________________________________
4) Vernik kaseosa :__________________________________________________
JANTUNG DAN PARU
1) Waktu Pengisian kapiler : ___________________________________________
2) Frekuensi denyut nadi/irama : ___________x / menit/________________________
3) Bunyi nafas : ___________________________________________
4) Frekuensi pernafasan : _______x/menit
PERUT DAN ABDOMEN
1) Gerakan diagpragmatik :___________________________________________

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 PUNGGUNG
1) Keadaan punggung : __________________________________________
2) Lanugo : __________________________________________
GENITALIA
1) Anus : __________________________________________
2) Keadaan :__________________________________________
EKTREMITAS
1) Jumlah jari tangan : __________________________________________
2) Jari kaki : __________________________________________
3) Pergerakan : __________________________________________
4) Garis telapak kaki :__________________________________________
5) Posisi kaki dan tangan :__________________________________________
STATUS NEUROLOGIS
Refleks – reflleks : __________________________________________
1) Tendon : __________________________________________
2) Moro : __________________________________________
3) Rooting :__________________________________________
4) Mengisap :__________________________________________
5) Babinski :__________________________________________
6) Menggenggam :__________________________________________
7) Menangis :__________________________________________
8) Tonus leher :__________________________________________
9) Lainnya (____________) : __________________________________________
NUTRISI
1) Jenis makanan :__________________________________________
2) Diberikan dengan :__________________________________________
3) Jumlah yang diberikan : __________________________________________

ProgramStudiProfesiNersJurusanKeperawatanFIKESUMG
 E. Pemeriksaan Diagnostic
(meliputi tanggal dan hasil pemeriksaan) meliputi Pemeriksaan Laboratorium, Foto
Rontgen, Data Tambahan
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ProgramStudiProfesiNersJurusanKeperawatanFIKESUMG
 F. PenatalaksanaanMedis
(Uraian sesuai dengan anjuran medis) meliputi Obat-obatan
Nama Obat Indikasi Kontraindikasi Efek Samping

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 Nama Obat Indikasi Kontraindikasi EfekSamping

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 G. IDENTIFIKASI DATA
1. Keluhan (Data Subjektif)
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2. Data Objektif
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 H. KLASIFIKASI/PENGELOMPOKKAN DATA BERDASARKAN GANGGUAN
KEBUTUHAN
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ProgramStudiProfesiNersJurusanKeperawatanFIKESUMG
I. ANALISA DATA BERDASARKAN PATOFISIOLOGI DAN PENYIMPANGAN
KDM
Penyakit ( Diagnsa Medis) Klien :
Respon utama :
Penyimpangan KDM :
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J. RUMUSAN DIAGNOSA KEPERAWATAN
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