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YAYASAN HAJI SOEHEILY QARI

SEKOLAH TINGGI ILMU KESEHATAN (STIKES)


MERANGIN
PRODI D III KEBIDANAN
Jln.BangkoKerinci Km.6 Kungkai, Kecamatan Bangko Kabupaten Merangin
email.stikes.merangin@yahoo.com
FORMULIR PENGKAJIAN PADA NEONATUS
Tempat praktek

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

Nama Mahasiswa

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

Nomor MR

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

No.Absen

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

Keterampilan ke

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

Masuk RS.H/Tgl/Jam :.............................

1. PENGKAJIAN DATA
A. Identitas/Biodata
1. Identitas Bayi
a. Nama
:..................................................
b. Umur
:..................................................
c. Tgl/Jam Lahir
:..................................................
d. Jenis kelamin
:..................................................
e. No. Status Registrasi
:..................................................
2. Identitas Orang Tua
Istri
Suami
Nama
:................................................. ...................................................
Umur
:.................................................. ...................................................
Agama
:.................................................. ...................................................
Suku/Bangsa
:.................................................. ...................................................
Pendidikan
:.................................................. ...................................................
Pekerjaan
:.................................................. ...................................................
Alamat

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

B. Anamnesia (Data Subjektif)


Pada tanggal :...................................pukul :................................
1. Riwayat Penyakit Kehamilan
NO

PENYAKIT

TM I

TM II

TM III

2. Kebiasaan Waktu Hamil


a. Makanan
:..................................................................................
b. Obat- obatan/ Jamu
:..................................................................................
c. Merokok
:..................................................................................
d. Alkohol
:..................................................................................
e. Dll
:..................................................................................
3. Riwayat Persalinan Sekarang
a. Jenis Persalinan
:..................................................................................
b. Ditolong Oleh
:..................................................................................
c. Lama Persalinan
: Kala l
:........... jam ...........menit

Kala ll
:........... jam ...........menit
4. Ketuban pecah
Spontan/amniotomi lamanya........jam, jumlahnya....... cc, warna.........., bau........
5. Komplikasi Persalinan
a. Ibu
:.....................................
b. Bayi
:.....................................
6. Keadaan Bayi
NO
1
2
3
4
5

ASPEK YANG DINILAI


Pernafasan
Denyut Jantung
Refleks
Tonus otot
Warna kulit
Jumlah

7. Tindakan Bidan Lainnya


Resusitasi : Tidak ada
a. Penghisapan Lendir
b. Ambubag
c. Masase Jantung
d. Induksi Endotrakea
e. Oksigen
f. Therapy
g. Keterangan

1 5 I

5 10 II

:.................................................................
:.............................. Lamanya
:......................
:.............................. Lamanya
:......................
:.............................. No
:......................
:.............................. Lamanya
:......................
:..............................
:..............................

8. Eliminasi
a. Miksi/BAK :..........Warna : .........., Tanggal.............Selanjutnya ...... kali/hari
b. Mekonium/BAB
:............Warna
:
....................,
Tanggal...............,
selanjutnya ............kali/hari
C. PEMERIKSAAN FISIK (DATA OBYEKTIF)
1. Pemeriksaan Umum
a. KU
:..........................................................................................................
b. Suhu
:..........................................................................................................
c. Pernafasan :..........................................................................................................
d. Nadi
:..........................................................................................................
e. BB
:..........................................................................................................
f. TB
:..........................................................................................................
2. Pemeriksaan Khusus
1) Pemeriksaan Fisik
a. Kepala
:..............................................................................................
b. Muka
:..............................................................................................
c. Mata
:..............................................................................................
d. Telinga:..............................................................................................
e. Hidung
:..............................................................................................
f. Tenggorokan :..............................................................................................
g. Mulut
:..............................................................................................
h. Leher
:..............................................................................................
i. Dada
:..............................................................................................
j. Abdomen
:..............................................................................................
k. Punggung
:..............................................................................................
l. Kulit
:..............................................................................................
m. Ekstenitas
:..............................................................................................

Atas/bawah
n. Genitalis
o. Anus

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

2) Reflek
a. Reflek Moro
b. Reflek Rooting
c. Reflek Walking
d. Reflek Graphs/ Plantar
e. Refleks Sucking
f. Refleks Tonisneck

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

3) Antropomutri
a. Lingkar Kepala (LK) :..................................................................................
b. Lingkar Dada (LD) :..................................................................................
c. LILA
:..................................................................................
4) Cap Kaki
Telapak Kaki Kiri Bayi

Telapak Kaki Kanan Bayi

Cap Jempol kiri Ibu

Cap Jempol Kanan Ibu

D. Pemeriksaan penunjang / laboratorium


1. Urine : Protein
Gula
2. Darah : Hb

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

3. Ro

Golongan Darah

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

Hb/SAG

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

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

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