FORMAT PENGKAJIAN NEONATALKEPERAWATAN ANAK

NAMA : ………………………………………………………………………………………NIM : ………………………………………………………………………………………TINGKAT / SEMESTER : ………………………………………………………………………………………TANGGAL PRAKTIK : ………………………………………………………………………………………TEMPAT PRAKTIK : ………………………………………………………………………………………

1. PENGKAJIANA. IDENTITAS KLIEN DAN KELUARGA :

Inisial bayiJenis kelaminNomor gelangTanggal / jam lahir / U m u r Tanggal MRS / PukulTanggal Pengkajian / Pukul

Nama informan Hubungan dengan pasienPekerjaanPendidikanAlamat Status Golongan darah

: ..........................................................................................................: ..........................................................................................................: ..........................................................................................................: ..........................................................................................................: ..........................................................................................................: ..........................................................................................................

: ..........................................................................................................: ..........................................................................................................: ..........................................................................................................: ..........................................................................................................: ..........................................................................................................: ..........................................................................................................: ..........................................................................................................

B. RIWAYAT KEPERAWATAN DAN KESEHATAN1. RIWAYAT NEONATUSa. Apgar Score / AS : 1’ 5’ 10’b. Umur kehamilan :.......................................................................................................................c. BBL :.......................................................................................................................d. PBL :.......................................................................................................................e. Cara persalinan :.......................................................................................................................f. Indikasi persalinan :........................................................................................................................g. Komplikasi persalinan :.......................................................................................................................h. Diagnosa medis : .......................................................................................................................

2. RIWAYAT MATERNALa. Umur : .......................................................................................................................b. G ..... P .................c. Cara persalinan : .......................................................................................................................d. Indikasi :.......................................................................................................................e. Kehamilan

ANC :....................................................................................................................... Kondisi Hamil : .......................................................................................................................

C. PEMERIKSAAN FISIK1. Keadaan umum : .......................................................................................................................

a. Kesadaran : .......................................................................................................................b. BB :.......................................................................................................................

c. PB :......................................................................................................................2. Tanda-tanda vitala. Suhu :.......................................................................................................................b. Nadi :.......................................................................................................................c. RR :.......................................................................................................................d. TD :.......................................................................................................................

3. Reflek a. Moro :.......................................................................................................................b. Sucking :.......................................................................................................................c. Menelan :.......................................................................................................................d. Rooting :.......................................................................................................................e. Reflek primitif lain :.......................................................................................................................

4. Kepala a. Fontanela :.......................................................................................................................b. Sutura :.......................................................................................................................c. Molding :.......................................................................................................................d. Rambut :.......................................................................................................................e. Caput succedanium :.......................................................................................................................f. Caput haematoma :.......................................................................................................................

5. Telinga Hidung dan Tenggorokana. Telinga :.......................................................................................................................b. Hidung :.......................................................................................................................c. Palatum :.......................................................................................................................

6. Dadaa. Thorak : .......................................................................................................................b. Klavikula :.......................................................................................................................

7. Paru ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

8. Jantung......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9. Abdomen......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

10. Ekstremitas ....................................................................................................................................................................................................................................................................................................................................................................

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11. Genetalia ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

12. Anus ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

13. Kulit......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

14. Kelainan Kongenital......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

D. PEMERIKSAAN PENUNJANG1. Laboratorium

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2. Radiologi......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. USG......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Lain-lain......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

E. DIAGNOSA MEDIS......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

F. PENATALAKSANAAN TERAPI........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................