Format Pengkajian Neonatus

Format Pengkajian Neonatus

PENGKAJIAN KEPERAWATAN USIA NEONATUS

Nama Mahasiswa                               :

NIM                                       :

Ruang                                                    :

Tanggal Pengkajian            :

Tanggal Praktek                  :

Paraf                                      :

I.              IDENTITAS KLIEN

Nama                                                 :

Tempat/tanggal lahir                      :

Umur                                                  :

No Register                                       :

Diagnosa Medis                               :

Nama Ayah/Ibu                              :

Pekerjaan Ayah                               :

Pendidikan Ayah                             :

Pekerjaan Ibu                                  :

Pendidikan Ibu                                :

Alamat/No.Telp                               :

Agama                                               :

II.            KELUHAN UTAMA

 

III.         RIWAYAT KEHAMILAN DAN KELAHIRAN

A.      Prenatal

1.       Jumlah kunjungan                  :

 

2.       Bidan/dokter                            :

3.       Penkes yang didapat              :

4.       HPHT                                        :

5.       Kenaikan BB selama hamil  :

6.       Komplikasi kehamilan           :

7.       Komplikasi obat                      :

8.       Obat-obatan yang didapat    :

 

9.       Riwayat hospitalisasi              :

 

10.    Golongan darah ibu                :

11.    Pemeriksaan kehamilan/Maternal screening

        (  ) Rubella                                (  ) Hepatitis                                          (  ) CMV

        (  ) GO                                        (  ) Herpes                                              (  ) HIV

        (   )   Lain-lain,sebutkan

 

B.      Natal

1.       Awal persalinan                       :

 

2.       Lama persalinan                     :

 

3.       Komplikasi persalinan            :

 

4.       Terapi yang diberikan            :

5.       Cara melahirkan

(  ) pervaginam                         (  ) SC

(   )   Lain-lain,sebutkan ……………………………………………………

6.       Tempat melahirkan

(  ) Rumah bersalin                  (  ) Rumah                             (  ) Rumah Sakit

7.       Penolong persalinan                :

C.      Postnatal

1.       Usaha nafas

(  ) dengan bantuan

(  ) tanpa bantuan

2.       Kebutuhan resusitasi

a.       Jenis dan lamanya          :              

b.       Skor APGAR                    :

	0	1	2	Interprestasi 7-10: Bayi Normal 4-6: Rendah 0-3: Sangat Rendah
Appereance				Warna Kulit
Pulse				Denyut Jantung
Grimace				Respon Refleks
Activity				Tonus Otot
Respiration				Pernafasan
Skor Apgar

3.       Obat-obatan yang diberikan kepada neonatus                :

4.       Interaksi orang tua dan bayi

a.       Kualitas             :

b.       Kuantitas          :

5.       Trauma lahir

(  ) ada

(  ) tidak ada

6.       Narcosis

(  ) ada

(  ) tidak ada

7.       Keluarnya urine/BAB

(  ) ada

(  ) tidak ada

8.       Respon fisiologis atau perilaku bermakna         :

IV.          RIWAYAT KELUARGA

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V.            GENOGRAM

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VI.          RIWAYAT SOSIAL

A.      Sistem pendukung/keluarga terdekat yang dapat dihubungi :

__________________________________________________________________________________________________________________________________________________________________

B.      Hubungan orang tua dengan bayi               :

Ibu		Ayah
	Menyentuh
	Memeluk
	Berbicara
	Berkunjung
	Kontak mata

C.      Anak yang lain

Jenis Kelamin Anak	Riwayat Persalinan	Riwayat Imunisasi

D.      Lingkungan rumah         :

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E.       Problem sosial yang penting

(  ) Kurangnya sistem pendukung sosial

(  ) Perbedaan bahasa

(  ) Riwayat penyalahgunaan zat adiktif (obat-obatan)

(  ) Lingkungan rumah yang kurang memadai

(  ) Keuangan

(   )   Lain-lain,sebutkan …………………………………………………………

VII.       KEADAAN KESEHATAN SAAT INI

A.      Diagnosa medis               :

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B.      Tindakan operasi            :

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C.      Status nutrisi                     :

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D.      Status cairan                    :

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E.       Obat-obatan                     :

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F.       Aktivitas                            :

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G.      Tindakan keperawatan yang telah dilakukan          :

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H.      Hasil laboratorium          :

	Hasil	Satuan	Remark	Nilai Rujukan

	Hasil	Satuan	Remark	Nilai Rujukan

I.        Pemeriksaan penunjang                :

 

VIII.     PEMERIKSAAN FISIK

A.      Keadaan umum

1.             Kesadaran            :

2.             Tanda vital           :

 

3.             Antropometri        :

	Saat lahir	Saat ini
1. Berat badan
2. Panjang badan
3. Lingkar kepala

4.             Refleks

(  ) Moro                (  ) Menggenggam                (  ) Menghisap

(   )   Lain-lain,sebutkan …………………………………………………

5.             Tonus/aktivitas

a. (  ) Aktif             (  ) tenang              (  ) letargi               (  ) kejang

b. (  ) Menangis keras                          (  ) lemah               (  ) melengking             

    (  ) sulit menangis

6.             Kepala/leher

a.       Fontanel anterior

(  ) Lunak           (  ) Tegas                 (  ) Tegas                          (  ) datar

(  ) Menonjol                       (  ) Cekung

b.       Sutura sagitalis

(  ) Tepat                        (  ) Terpisah                   (  ) Menjauh

c.        Gambaran wajah

(  ) Simetris    (  ) Asimetris

d.       Holding

(  ) Caput succedaneum                   (  ) Chepalohematoma

7.             Mata

(  ) Bersih                               (   )   Sekresi, ……………………………………

8.             THT

a.       Telinga

(  ) Normal                 (  ) Abnormal

b.       Hidung

(  ) Bilateral               (  ) Obstruksi                     (  ) Cuping hidung

c.        Palatum

(  ) Normal                 (  ) Abnormal

9.             Abdomen

a. (  ) Lunak              (  ) Tegas                  (  ) Datar                 (  ) Kembung

b. Lingkar perut: ………. Cm

c. Liver: (  ) kurang dari 2 cm        (  ) lebih dari 2 cm

10.          Toraks

a. (  ) Simetris        (  ) Asimetris

b. Retraksi:  (  ) derajat 1   (  ) derajat 2                  (  ) derajat 3

c. Klavikula:  (  ) normal                    (  ) abnormal

11.          Paru-paru

a. Suara nafas: (  ) sama kanan kiri                  ( ) tidak sama kanan kiri         (  ) bersih               (  ) ronchi                        (  ) rales                (  ) sekret

b. Bunyi nafas

        (  ) terdengar di semua lapang paru                (  ) tidak terdengar                    (  ) menurun

c.        Respirasi

(  ) spontan, jumlah:         x/menit

(  ) sungkup/boxhead, jumlah:        x/menit

(  ) ventilasi assisted CPAP

12.          Jantung

a. (  ) bunyi normal sinus rhytm (NSR), jumlah:         x/menit

    (  ) murmur                        (     )   Lain-lain,sebutkan ………………………

b.      Waktu pengisian kapiler  : batang tubuh ……………………………

                                                      extremitas ……………………………….

c.       Nadi perifer

	Kuat	Lemah	Tidak ada
Brakhial-kanan
Brakhial-kiri
Femoral-kanan
Femoral-kiri

13.          Extremitas

a. (  ) Semua extremitas gerak          (  ) ROM terbatas (  ) tidak dapat dikaji

b. Extremitas atas dan bawah  (  ) simetris     (  ) asimetris

14.          Umbilikus

(  ) normal             (  ) abnormal         (  ) inflamasi         (  ) drainase

15.          Genital

(  ) perempuan normal        (  ) laki-laki normal              (  ) ambivalen

16.          Anus

(  ) paten                                (  ) imperforata

17.          Spina

(  ) normal                             (  ) abnormal

18.          Kulit

a.       Warna

(  ) pink                          (  ) pucat                                (  ) jaundice

b.       (  ) rash/kemerahan

c.        (  ) tanda lahir

19.          Suhu

a.       Lingkungan

(  ) penghangat radian                (  ) pengaturan suhu            (  ) inkubator   (  ) suhu ruang                            (  ) boks terbuka                    

b.       Suhu kulit      :

IX.         INFORMASI LAIN

 

X.            RINGKASAN RIWAYAT KEPERAWATAN

 

XI.         ANALISA DATA

NO	TANGGAL/JAM	DATA FOKUS	PENYEBAB	MASALAH
	………………….…………………..…………………..…………………..…………………..…………………..…………………..…………………..…………………..…………………..…………………..…………………..…………………..…………………..…………………..…………………..	………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ………………………………………………………………………………. ……………………………………………………………………………….	………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. ………………………………………….. …………………………………………..	……………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

NO	TANGGAL/JAM	DATA FOKUS	PENYEBAB	MASALAH
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XII.       DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS

1.

 

XIII.    RENCANA KEPERAWATAN

NO	DIAGNOSA KEPERAWATAN	TUJUAN & KRITERIA HASIL	INTERVENSI	RASIONAL
	……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………...	……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………...	………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............	……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………...

NO	DIAGNOSA KEPERAWATAN	TUJUAN & KRITERIA HASIL	INTERVENSI	RASIONAL
	……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………...	……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………... ……………………………………...	………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............ ………………………………………………………............	……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………... ……………………………………………….. ………………………………………………...

XIV.     CATATAN PERKEMBANGAN

NO	TANGGAL	NO. DX	JAM	IMPLEMENTASI	EVALUASI	NAMA/TTD
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XV.    EVALUASI SUMATIF

NO DX	EVALUASI	PARAF/NAMA
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				by: ners muda