Professional Documents
Culture Documents
I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama : ............................................
Umur : ............................................
Umur : ............................................
Pendidikan : ............................................
Pekerjaan : ............................................
Agama : ............................................
Suku : ............................................
Alamat : ............................................
No.CM : ............................................
C. RIWAYAT PERSALINAN
BB/TB Ibu : ............kg/................cm Persalinan di...............
Kala I.................................Jam
Indikasi : ..........................................
Kala II .......................menit
Komplikasi persalinan : Ibu................................. Janin ........................
Kelahiran : Tunggal/gemeli
Nilai APGAR
Tanda Nilai Jumlah
0 1 2
Denyut jantung Tidak ada < 100 >100
Usaha napas Tidak ada Lambat Menangis
kuat
Tonus otot Lumpuh Ekstremitas Gerakan aktif
fleksi sedikit
Iritabilitas reflex Tidak Gerakan Reaksi
bereaksi sedikit melawan
Warna Biru/pucat Tubuh Kemerahan
kemerahan,
tangan dan
kaki biru
E. PENGKAJIAN FISIK
Umur ..............Hari....................Jam..........
Berat badan.................................gr
Panjang badan.............................cm
Suhu...........................................C
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 Kelainan : ...............................................
o Perempuan : ..............................................
o Anus : ...............................................
o Mekonium : ...............................................
o Kelainan : ...............................................
Ekstremitas
o Atas : .............................................................
o Bawah : ............................................................
o Kelainan : .............................................................
o Pergerakan : ...........................................................
F. STATUS NEUROLOGI
Pemeriksaan refleks :
G. NUTRISI
ASI/PASI/Lain-lain
H. ELIMINASI
BAB pertama, tanggal ........................ Jam..................
BAK pertama, tanggal ........................ Jam..................
I. DATA PENUNJANG
o Pemeriksaan Laboratorium :..
K. PENGOBATAN
2. ........................................
3. ........................................
III. RENCANA KEPERAWATAN
Denpasar, .2017
Mengetahui
Pembimbing Klinik/ CI Mahasiswa
(................) (..........)
NIP: NIM:
(...................................................................)
NIP.