FORMAT ASUHAN KEPERAWATAN NEONATUS

ASUHAN KEPERAWATAN PADA By.................. DENGAN .........................................

DI RUANG .......................... RS ..
PADA TANGGAL ..................................................................

Nama mahasiswa : ........................................................................................................

NIM : ........................................................................................................
Tempat Praktek : ........................................................................................................
Tanggal Pengkajian : ........................................................................................................
Tanggal praktek : ........................................................................................................

A. Identitas Pasien
Nama : ........................................................................................................
Tempat/tgl lahir : ........................................................................................................
Umur : ........................................................................................................
No register : ........................................................................................................
Diagnose medis : ........................................................................................................
Tanggal MRS : ........................................................................................................
Nama ayah/ibu : ........................................................................................................
Pekerjaan Ayah : ........................................................................................................
Pendidikan Ayah : ........................................................................................................
Alamat/No Telp : ........................................................................................................
Agama : ........................................................................................................

B. Keluhan Utama
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aat MRS
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aat Pengkajian
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C. Riwayat Penyakit Sekarang
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D. Riwayat Kehamilan Dan Kelahiran

1. Prenatal
 Jumlah kunjungan/ANC.................................................:

Tempat............................................................................:
(dokter / Bidan / Lainya)
Penkes yang diperoleh
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HPHT..............................................................................:

Kenaikan BB selama hamil............................................:

Komplikasi kehamilan
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Komplikasi obat
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Obat-obatan yg didapat
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Riwayat hospitalisasi
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Golongan darah ibu.........................................................:
A / B / AB / O
Pemeriksaan kehamilan (maternal screening)
( ) Rubella ( ) Hepatitis ( ) CMV
( ) GO ( ) Herpes ( ) HIV
Lainnya : .............................................................................................................................
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2. Natal
Awal persalinan...............................................................:

Lama persalinan..............................................................:
 Saat persalinan................................................................:
premature / matur / serotinus
Komplikasi persalinan....................................................:

Terapi yang diberikan.....................................................:

Cara melahirkan
( ) pervaginam normal ( ) SC
( ) vakum ekstasion ( ) Lainnya : ....................................................
Tempat melahirkan
( ) Rumah Sakit ( ) Rumah bersalin
( ) Rumah ( ) Lainnya : ....................................................
Penolong persalinan .......................................................:

3. Post Natal
Usaha nafas
( ) dengan bantuan ( ) tanpa bantuan
Kebutuhan resusitasi
Jenis dan lamanya : ......................................................................................
......................................................................................
APGAR Skor..................................................................:

Bayi langsung menangis : ya / tidak

Tangisan bayi..................................................................:
kuat / lemah / lainnya
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bat-obatan yang diberikan pada neonates
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Interaksi orangtua dan bayi

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Trauma lahir : ( ) ada ( ) tidak
Narcosis : ( ) ada ( ) tidak
Keluarnya urine/BAB : ( ) ada ( ) tidak
Respon fisiologis atau perilaku bermakna
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E. Riwayat Keluarga (GENOGRAM)

F. Riwayat Sosial
1.....................................................................................................................................S
istem pendukung/keluarga terdekat yang dapat dihubungi
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2. Hubungan orang tua dengan bayi
Menyentuh : Ibu ( ) Bapak ( )
Memeluk : Ibu ( ) Bapak ( )
Berbicara : Ibu ( ) Bapak ( )
Berkunjung : Ibu ( ) Bapak ( )
Kontak mata : Ibu ( ) Bapak ( )

3. Anak yang lain

Anak ke- Jenis kelamin Riwayat persalinan Riwayat imunisasi

4.....................................................................................................................................L
ingkungan rumah
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5. Problem sosial yang penting
( ) Kurangnya system pendukung social
( ) Perbedaan bahasa
( ) Riwayat penyalahgunaan zat adiftif (obat-obatan)
( ) Lingkungan rumah yang memadai
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) Keuangan , penghasilan/bulan : Rp ...........................................................................
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) lain-lain, sebutkan ......................................................................................................
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G. Keadaan Kesehatan Saat Ini

1. Diagnose medis...........................................................................:

2. Tindakan operasi.........................................................................:

3. Status nutrisi dan cairan

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ebelum sakit
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elama sakit
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4. Obat-obatan

Nama obat Dosis Rute Indikasi

 5. Aktivitas
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ebelum sakit
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elama sakit
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6.....................................................................................................................................T
indakan keperawatan yang telah dilakukan
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7.....................................................................................................................................H
asil Laboratorium
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8.....................................................................................................................................P
emerikasaan Penunjang
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9.....................................................................................................................................L
ain-lain
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H. Pemeriksaan Fisik
1. Keadaan umum...........................................................................:

2. Kesadaran...................................................................................:
(Composmetris/ Apatis/ Somnolen/ Supor/ Coma)
2. Tanda-tanda vital
TD...............................................................................................:

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

Suhu............................................................................................:
 RR...............................................................................................:

3. Antropometri
Saat lahir Saat ini
1. Berat badan
2. Panjang badan
3. Lingkar kepala
4. Lingkar dada
5. Lingkar lengan atas
6. Lingkar perut

4. Reflex
( ) Moro ( ) Menggenggam ( ) Menghisap
( ) lain-lain, sebutkan ................................................................................................
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5. Tonus/aktivitas
( ) Aktif ( ) Tenang ( ) Letargi ( ) Kejang
( ) Menangis keras ( ) Lemah
( ) Melengking ( ) Sulit mengangis
6. Kepala/leher
Fontanel anterior
( ) Lunak ( ) Tegas ( ) Datar
( ) Menonjol ( ) Cekung
Sutura sagitalis
( ) Tepat ( ) Terpisah ( ) Menjauh
Gambaran wajah
( ) Simetris ( ) Asimetris
Holding
( ) Caput succedaneum ( ) Chepalohematoma
7. Mata
( ) Bersih ( ) Sekresi
8. THT
Telinga
( ) Normal ( ) Abnormal
Hidung
( ) Bilateral ( ) Obstruksi ( ) Cuping hidung
Palatum
( ) Normal ( ) Abnormal
9. Thoraks
( ) Simetris ( ) Asimetris
Retraksi : ( ) Derajat I ( ) Derajat II ( ) Derajat III
Klavikula : ( ) Normal ( ) Abnormal
 10. Paru-paru
Suara nafas
( ) sama kanan-kiri ( ) tidak sama kanan-kiri ( ) Bersih
( ) Ronchi ( ) Rales ( ) Sekret
Bunyi nafas
( ) Terdengar di semua lapang paru
( ) Tidak terddengar ( ) Menurun
Respirasi
( ) Spontan, jumlah : ...........................................................................................
( ) Sungkup/ Boxhead, jumlah : .........................................................................
( ) Ventilasi assisted CPAP
11. Jantung
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) Bunyi normal sinus rhytm (NSR), jumlah : .........................................................
( ) Murmur ( ) lain-lain, sebutkan : ................................................................
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Waktu pengisian kapiler : batang tubuh..:

Ekstremitas : ..............................................................
Nadi perifer
Kuat Lemah Tidak ada
Brachial kanan
Brachial kiri
Femoral kanan
Femoral kiri

12. Abdomen
( ) Lunak ( ) Tegas ( ) Datar ( ) Kembung
Liver : ( ) kurang dari 2 cm ( ) lebih dari 2 cm
Umbilicus
( ) Normal ( ) Abnormal ( ) Inflamasi ( ) Drainase
13. Ekstremitas
( ) semua ekstremitas gerak( ) ROM terbatas ( ) tidak dapat dikaji
Ekstremitas atas dan bawah : ( ) Simetris ( ) Asimetris
14. Genital
( ) Perempuan normal ( ) laki-laki normal ( ) Ambivalen
15. Anus
( ) Paten ( ) Imperforata
16. Spina
( ) Normal ( ) Abnormal
17. Kulit
Warna : ( ) Pink ( ) Pucat ( ) Jaundice
( ) Rash/kemerahan
( ) Tanda lahir
 18. Suhu
Lingkungan
( ) Penghangat radian ( ) Pengaturan suhu ( ) Inkubator
( ) Suhu ruang ( ) Boks terbuka
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uhu kulit : ...............................................................................................................

I. Pemeriksaan Refleks Patologis

( ) Babinsky ( ) Chaddock ( ) Oppenheim
( ) Gordon ( ) Schaeffer ( ) Hoffman
( ) Tromner

J...........................................................................................................................................I
nformasi Lain
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K..........................................................................................................................................R
ingkasan Riwayat Keperawatan
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