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ASUHAN KEPERAWATAN NEONATAL

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PENGKAJIAN

Tanggal MRS/Jam :

Tanggal Pengkajian/Jam :

Tempat :

A. DATA SUBYEKTIF

1. Identitas

Nama Bayi :...............................................................................................................................

Tanggal/Jam Lahir :...............................................................................................................................

Jenis Kelamin :................................................................................................................................

Umur :...............................................................................................................................

Dx Medis :................................................................................................................................

2. Keluhan Utama

a) Saat MRS :……………..............................................................................................................

..................................................................................................................................

b) Saat Pengkajian :………………..........................................................................................................

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3. Identitas Orang Tua

4. Riwayat Prenatal

- Kehamilan ke :....................................................................................................................

Ayah Ibu

Nama

Umur

Suku/Bangsa

Agama

Pendidikan

Pekerjaan

Alamat

:

:

:

:

:

:

:

:

:

:

:

:

:

:

- Tempat ANC :....................................................................................................................

- Imunisasi TT :.....................................................................................................................

- Obat-Obatan yang pernah diminum selama hamil :..........................................................................

- Penerimaan Ibu/Keluarga Terhadap kehamilan :.........................................................................

- Masalah yang pernah dialami ibu saat hamil :...........................................................................

4. Riwayat IntraNatal

- Persalinan ke :..........................................................................................................

- Tempat dan penolong persalinan :..........................................................................................................

- Masalah saat persalinan :...........................................................................................................

- Jenis Persalinan :............................................................................................................

- Lama persalinan :.............................................................................................................

- Keadaan bayi saat lahir :.............................................................................................................

- Segera menangis/tidak :..............................................................................................................

5. Riwayat Natal

- Keadaan bayi baru lahir

- Lahir tanggal : .....................................,jam..........................................................

- Masa gestasi : ........................................ minggu

- BB/PB lahir :.........................gram, ......................cm

- Nilai APGAR : 1 menit/5menit/10 menit/2 jam:

No Kriteria 1 menit 5 menit 10 menit 2 jam

1 Denyut Jantung

2 Usaha nafas

3 Tonus otot

4 Reflek

5 Warna kulit

TOTAL

6. Pola Fungsi kesehatan

Kebutuhan Dasar Saat MRS Saat Pengkajian

1. Cairan & Makanan

2. Eliminasi

3. Istirahat & Tidur

4. Personal hygiene

5. Aktivitas

7. Status Imunisasi :.......................................................................................................................................

B. DATA OBJEKTIF

1. Pemeriksaan Umum

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

b. kesadaran : ......................................................................................................................................

c. Tanda vital

Nadi :.......................................................................................................................................

Pernafasan :.....................................................................................................................................

Suhu :.......................................................................................................................................

2. Pemeriksaan Antropometri

BB :....................................................................................................................................................

PB :....................................................................................................................................................:

LK :....................................................................................................................................................

LD .....................................................................................................................................................:

LLA :....................................................................................................................................................

2. Pemeriksaan Fisik

Kepala : ...................................................................................................................................................

Muka :....................................................................................................................................................

Ubun-ubun : ....................................................................................................................................................

Mata : ....................................................................................................................................................

Hidung : ....................................................................................................................................................

Telinga : ....................................................................................................................................................

Mulut : ....................................................................................................................................................

Leher : ....................................................................................................................................................

Dada : ....................................................................................................................................................

Tali pusat : ....................................................................................................................................................

Abdomen : ....................................................................................................................................................

Punggung : ....................................................................................................................................................

Ekstermitas : ....................................................................................................................................................

Genitalia : ....................................................................................................................................................

Anus : ....................................................................................................................................................

3. Pemeriksaan Neurologis

Moro : ....................................................................................................................................................

Rooting : ....................................................................................................................................................

Sucking : ....................................................................................................................................................

Swallowing : ....................................................................................................................................................

Walking : ....................................................................................................................................................

Graphs : ....................................................................................................................................................

Tonicneck : ....................................................................................................................................................

Burning : ....................................................................................................................................................

5. Pemeriksaan Penunjang

a. Pemeriksaan Laboratorium

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b. Terapi

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B. ANALISA DATA

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No Tanggal / Jam Analisa Data Masalah Etiologi

C. DIAGNOSA KEPERAWATAN

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D. INTERVENSI.....................................................................................................................................................................................................

NO TANGGAL/JAM

KRITERIA HASIL INTERVENSI RASIONAL

NO TANGGAL/JAM

KRITERIA HASIL INTERVENSI RASIONAL

E. IMPLEMENTASI..............................................................................................................................................................................................

NO TANGGAL/JAM IMPLEMENTASI

NO TANGGAL/JAM IMPLEMENTASI

F. EVALUASI

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NO TANGGAL/JAM EVALUASI

NO TANGGAL/JAM EVALUASI