ASUHAN KEPERAWATAN PADA By..................

DENGAN.........................................
DI RUANG..........................
RS………………………..
TANGGAL..........

I PENGKAJIAN
i. IDENTITAS PASIEN

Nama : ............................................
Umur : ............................................
Nama Ayah-Ibu : ............................................

Umur : ............................................
Pendidikan : ............................................
Pekerjaan : ............................................
Status perkawinan : ............................................

Agama : ............................................
Suku : ............................................
Alamat : ............................................
No.CM : ............................................

Tanggal MRS : ............................................

Tanggal pengkajian : ............................................
Sumber informasi : ............................................

ii. RIWAYAT KELAHIRAN

No Tahun Jenis BB Keadaan Komplikasi Jenis Ket
kelahiran kelamin lahir bayi persalinan
iii. RIWAYAT PERSALINAN
BB/TB Ibu : ............kg/................cm Persalinan di...............
Keadaan umum Ibu .........................Tanda vital .................
Jenis persalinan ...............................Proses persalinan.......

Kala I ................................ Jam

Indikasi : ..........................................Kala II ....................... menit
Komplikasi persalinan : Ibu.................................Janin ........................

Lamanya ketuban pecah ...................................... Kondisi ketuban....

iv. KEADAAN BAYI SAAT LAHIR

Lahir tanggal : ...................jam............ Jenis kelamin.............

Kelahiran : Tunggal/gemeli
Nilai APGAR
Tanda Nila Jumlah
i
0 1 2
Denyut Tidak ada < 100 >100
jantung
Usaha napas Tidak ada Lambat Menangis
kuat
Tonus otot Lumpuh Ekstremitas Gerakan aktif
fleksi sedikit
Iritabilita Tidak Gerakan Reaksi
sreflex bereaksi sedikit melawan
Warna Biru/pucat Tubuh Kemerahan
kemerahan,
tangan dan
kaki biru
v. PENGKAJIAN FISIK
Umur ..............Hari....................Jam..........
Berat badan.................................. gr
Panjang badan ............................. cm
Suhu............................................ ºC
Lingkar kepala............................. cm
Lingkar dada............................... cm
Lingkar perut ............................. cm

Head to toe
Kepala Wajah
o Inspeksi : .............................................................
o Palpasi : .............................................................

Leher
o Inspeksi : .............................................................
o Palpasi : .............................................................

Tubuh
o Warna :……………………………………………
o Lanugo :……………………………………………
o Vernix :……………………………………………

Dada
o Inspeksi :.................................................
o Palpasi :.................................................

o Perkusi :.................................................
o Auskultasi : …………........................................

Abdomen
o Inspeksi :.............................................................
o Auskultasi : ............................................................
 o Perkusi :.............................................................
o Palpasi : .............................................................

Punggung
o Keadaan punggung : ...............................................
o Fleksibilitas : ...............................................
o Tulang punggung : ...............................................
o Kelainan : ...............................................

Genetalia dan anus

o Laki-laki : ...............................................
o Perempuan : ...............................................
o Anus : ...............................................
o Mekonium : ...............................................
o Kelainan : ...............................................

Ekstremitas
o Atas : .............................................................
o Bawah : .............................................................
o Kelainan : .............................................................
o Pergerakan : ...........................................................

vi. STATUS NEUROLOGI

Pemeriksaan refleks : .................................................

vii. NUTRISI
ASI/PASI/Lain-lain

viii. ELIMINASI
BAB pertama, tanggal ........................ Jam..................
BAK pertama, tanggal ........................ Jam..................
ix. DATA PENUNJANG
o Pemeriksaan Laboratorium :

o Pemeriksaan Diagnostik :

x. DIAGNOSA MEDIS

xi. PENGOBATAN
II. ANALISA DATA

Data Fokus Analisis Masalah

 Diagnosa keperawatan berdasarkan prioritas :
1. ...........................................................................................................................................
...........................................................................................................................................
..........................................................................................................................................
2. ...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
3. ...........................................................................................................................................
...........................................................................................................................................
.........................................................................................................................................

III. RENCANA KEPERAWATAN

No Tgl / Diagnosa Rencana Keperawatan

jam Tujuan Intervensi Rasional
IV. IMPLEMENTASI

Tgl/ Diagnosa Implementasi Respon Paraf/

Jam Nama
V. EVALUASI

Tgl/ Diagnosa Evaluasi Hasil Paraf

Jam