FORMAT DOKUMENTASI

ASUHAN KEPERAWATAN PADA BAYI

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Disusun Oleh :
NAMA : …………….........................
NIM : ………………………………..

KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN KEMENKES
MALANG
JURUSAN KEPERAWATAN
PROGRAM STUDI SARJANA TERAPAN
FORMAT PENGKAJIAN
KEPERAWATAN MALANG
 A. PENGKAJIAN

A1. PENGUMPULAN DATA

I. BIODATA

IDENTITAS BAYI IDENTITAS BAPAK

Nama :..................................... Nama :.....................................
No. Register :..................................... Umur :.....................................
Umur :..................................... Jenis kelamin :.....................................
Jenis kelamin :..................................... Alamat :.....................................
Alamat :..................................... Pendidikan :.....................................
Suku bangsa :..................................... Pekerjaan :.....................................
Tanggal lahir/Umur :..................................... Suku bangsa :.....................................
Tgl MRS :..................................... No. Tlp/HP
Tanggal pengkajian :..................................... :.....................................
Diagnosa medis :..................................... IDENTITAS IBU :.....................................
Urutan anak : ....................................
Nama :.....................................
Umur :.....................................
Jenis kelamin :.....................................
Alamat :.....................................
Pendidikan :.....................................
Pekerjaan :.....................................
Suku bangsa :.....................................
No. Tlp/HP :.....................................

II. KELUHAN UTAMA/ALASAN KUNJUNGAN

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III. RIWAYAT KESEHATAN

A. RIWAYAT KEHAMILAN
1) Jumlah kunjungan ke bidan/dokter : ....................................................................................
2) Pendidikan kesehatan yang didapatkan : ............................................................................
3) Kenaikan BB selama hamil : ................................................................................................
4) Penyakit yang diderita ibu saat hamil : .................................................................................
5) Pemeriksaan Lab/Radiologi saat hamil: ...............................................................................
6) Keluhan saat hamil: .............................................................................................................
7) Imunisasi selama hamil: .......................................................................................................
8) Obat-obatan/vitamin yang dikonsumsi: .................................................................................
9) Riwayat minum jamu: ...........................................................................................................
10)Riwayat dipijat (Bhs Jawa: dioyok): ......................................................................................
 B. RIWAYAT KELAHIRAN
1) Lama persalinan: ..................................................................................................................
2) Komplikasi persalinan: .........................................................................................................
3) Cara persalinan: ........................................................................................
4) Tempat melahirkan: .............................................................................................................
5) Penolong persalinan: ...........................................................................................................
6) Usia gestasi: ........................................................................................................................
7) Kondisi air ketuban: ..............................................................................................................

C. RIWAYAT POST NATAL

1) Pernafasan/usaha bernafas (denga/tanpa bantuan): ........................................................
2) Tonus otot: ........................................................................................................................
3) Skor APGAR: ....................................................................................................................
4) Kebutuhan resusitasi (Jenis dan lamanya): ......................................................................
5) Obat yang diberikan: ........................................................................................................
6) Trauma lahir: ...................................................................................................................

IV. PEMERIKSAAN FISIK (HEAD TO TOE)

A. Keadaan Umum
Postur: .........................................................................................................................
Tangisan:
APVU:
B. Kepala dan rambut
Kebersihan : ...............................................................................................................
Bentuk kepala : ..........................................................................................................
Keadaan rambut :........................................................................................................
Keadaan kulit kepala : caput succedanum, cefalohematom: ....................................
Fontanela anterior : lunak/menonjol/tegas/cekung/datar: ........................................
Sutura sagitalis : tepat/terpisah/menjauh: .................................................................
Distribusi rambut : merata/tidak merata: ....................................................................
C. Mata
Kebersihan : ..................................................................................................................
Sclera : ..........................................................................................................................
Conjungtiva : .................................................................................................................
Pupil : .............................................................................................................................
Gerakan bola mata : .....................................................................................................
 Pupil: ...............................................................................................................................
Sekret: ............................................................................................................................
Jarak inner canthus: (normal, lebar) .................................................................................
D. Hidung
Pernafasan Cuping hidung : ..........................................................................................
Struktur :.........................................................................................................................
Kelainan lain : polip/perdarahan/peradangan: ...............................................................
Sekresi: ........................................................................................................................
E. Telinga
Kebersihan : .......................................................................................................................
Sekresi : .............................................................................................................................
Struktur : .............................................................................................................................
Fistulaaurikel: ....................................................................................................................
F. Mulut dan Tengorokan
Jamur (stomatitis, moniliasis): ...........................................................................................
Kelaianan bibir dan rongga mulut (gnato/labio/palato skizis): ............................................
Problem menelan : .............................................................................................................
Warna bibir: .............................................................................................................
G. Leher
Venajugularis : ...................................................................................................................
Arteri karotis : .....................................................................................................................
Pembesaran tiroid/limfe : ...................................................................................................
Torticoliis: ..........................................................................................................................
H. Dada/Thorak (jantung dan Paru)
Bentuk dada: ......................................................................................................................
Pergerakan dinding dada: ........................................................................................
Tarikan dinding dada ke atas/bawah: ..................................................................................
Suara pernafasan: ...............................................................................................................
Frekwensi nafas: .................................................................................................................
Abnormalitas suara nafas: .................................................................................................
Suara jantung: ....................................................................................................................
I. Ekstremitas atas
Tonus otot: ..........................................................................................................................
Trauma, deformitas: ..........................................................................................................
Kelainan struktur: ................................................................................................................
CRT: .............................................................................................................
J. Perut
Bentuk perut: ......................................................................................................................
 Bising usus: .........................................................................................................................
Ascites: .............................................................................................................
Massa: ...............................................................................................................
Turgor kulit: .......................................................................................................................
Vena: ..............................................................................................................................
Hepar: .............................................................................................................
Lien: .......................................................................................................................
Tali pusat: kebersihan, warna kulit sekitar .....................................................................
Distensi: ............................................................................................................................
K. Punggung
Spina bifida: ........................................................................................................................
Deformitas: ........................................................................................................................
Kelainan struktur: ................................................................................................................
L. Genetalia dan anus
Keadaan kelamin luar : ......................................................................................................
Anus : ...............................................................................................................................
Kelainan: ........................................................................................................................
M. Ekstremitas bawah
Tonus otot: .........................................................................................................................
Trauma, deformitas: .........................................................................................................
Kelainan struktur: ..............................................................................................................
N. Integumen
Warna kulit: ...................................................................................................................
Kelembaban: .....................................................................................................................
Lesi: ......................................................................................................................
Warna kuku, rambut: .......................................................................................................
Kelainan: ..........................................................................................................................

V. PENGUKURAN ANTROPOMETRI
Berat badan: ..........................................................................................................................
Panjang badan: .......................................................................................................................
Lingkar kepala: ......................................................................................................................
Lingkar dada: ..........................................................................................................................
Lingkar lengan Atas: ............................................................................................................
VI. REFLEKS PRIMITIF
Berkedip: ............................................................................................................................
Rooting : ............................................................................................................................
Menghisap :............................................................................................................................
 Menggenggam :........................................................................................................................
Neck
righting: ...........................................................................................................................Moro
: .............................................................................................................................

VII. RIWAYAT IMUNISASI

Sebutkan imunisasi yang sudah diberikan beserta umur saat diimunisasi
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VIII. PEMENUHAN KEBUTUHAN DASAR

A. OKSIGEN
Kebutuhan oksigen: ..........................................................................................................
Dosis oksigen: ...................................................................................................................
Cara pemberian: ..........................................................................................................
B. CAIRAN:
Kebutuhan cairan dalam 24 jam: .....................................................................................
Jenis cairan yang diberikan: ...........................................................................................
Cara/rute pemberian: .......................................................................................................
Balance cairan dalam 24 jam:
Intake: ..............................................................................................................................
Output : ............................................................................................................................
IWL: ..............................................................................................................................
Kesimpulan: ..................................................................................................................
C. Nutrisi
Kebutuhan kalori: ............................................................................................................
Bentuk/jenis nutrisi yang diberikan: ....................................................................................
Cara pemberian: .............................................................................................................
Frekwensi pemberian: ..................................................................................................
D. ELIMINASI URINE
Volume urine:..................................................................................................................
Warna:............................................................................................................................
Frekwensi:.........................................................................................................................
Cara BAK (spontan/kateter):............................................................................................

E. ELIMINASI ALVI
 Pengeluaran Mekoneum: ................................................................................................
Volume feses:...................................................................................................................
Warna feses:....................................................................................................................
Konsistensi: ......................................................................................................................
Frekwensi:.........................................................................................................................
Darah, lendir dalam feses:................................................................................................
F. TIDUR
Jumlah jam tidur dalam 24 jam: .....................................................................................
Kualitas tidur (sering terbangun, rewel, tidak bisa tidur): ...............................................
G. PSIKOSOSIAL
Yang mengasuh: ...........................................................................................................

IX. DATA PENUNJANG

A. Radiologi
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

B. Laboratorium
 Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

C. Pemeriksaan lainnya
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan
 Mengetahui, ...............................,......................................
Pembimbing klinik .

Mahasiswa

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NIM.