FORMAT PENGKAJIAN PADA BAYI BARU LAHIR / NEONATUS

A. IDENTITAS BIODATA
Nama Bayi : ..................................................................
Umur Bayi : .................................... ..............................
Tanggal / jam lahir : .................................... ..............................
Jenis Kelamin : .................................... ..............................
Berat Badan : .................................... ..............................
Panjang Badan : .................................... ..............................

Nama Ibu : .................................... .............................. Nama Bapak : .................................... ..............................

Umur : .................................... .............................. Umur : .................................... ..............................
Suku / Bangsa : .................................... .............................. Suku / Bangsa : .................................... ..............................
Agama : .................................... .............................. Agama : .................................... ..............................
Pendidikan : .................................... .............................. Pendidikan : .................................... ..............................
Pekerjaan : .................................... .............................. Pekerjaan : .................................... ..............................
Alamat Rumah : .................................... .............................. Alamat Rumah : .................................... ..............................
Telepon : .................................... .............................. Telepon : .................................... ..............................

B. ANAMNESA
Pada Tanggal : ........................................................................ Pukul : ...........................WIB
1. Riwayat kehamilan G .... P .... A
ANC : ...........................................................................................................................................................................
Kenaikan Berat Badan Ibu : ...........................................................................................................................................................................
Imunisasi TT : ................................................................................................................................................................. kali
2. Riwayat Penyakit Kehamilan
a) Perdarahan : ...........................................................................................................................................................................
b) Preeklamsia : ...........................................................................................................................................................................
c) Eklamsia : ...........................................................................................................................................................................
d) Penyakit Kelamin : ...........................................................................................................................................................................
e) Lain- lain : ...........................................................................................................................................................................
3. Riwayat Waktu Hamil
a) Makanan : ...........................................................................................................................................................................
b) Obat-obatan / jamu : ...........................................................................................................................................................................
c) Merokok : ...........................................................................................................................................................................
d) Alkohol : ...........................................................................................................................................................................
e) Lain –lain : ...........................................................................................................................................................................
4. Riwayat Persalinan Sekarang
a) Jenis Persalinan : ............................................................................ Ditolong oleh : ................................................
b) Lama Persalinan
- Kala I : ....................................................................................... Jam ........................................................................ Menit
- Kala II : ....................................................................................... Jam ......................................................................... Menit
- Lamanya : ...................................................................................... Jam ........................................................................ Menit
c) Ketuban Pecah
Spontan / Dipecahkan Pukul : .................................. WIB
Warna : ................... Bau / Tidak Jumlah : .................................. cc
d) Komplikasi Persalinan
Ibu : ...........................................................................................................................................................................
Bayi : ...........................................................................................................................................................................
Nilai APGAR
No. Kriteria 0-1 menit 1-5 menit

1 Denyut Jantung Bayi

2 Usaha Napas

3 Tonus Otot

4 Refleks

5 Warna Kulit

TOTAL
 e) Resusitasi
Pengisapan lendir : tidak / ya Rangsangan : tidak / ya
Massage jantung : tidak / ya Lamanya : tidak / ya
Intubasi endotrabesi : tidak / ya Nomor ; ..................................................
Oksigen : tidak / ya Lamanya : ........................ tetes / menit
Therapi : ........................................................................................................................................................................................
Keterangan : ........................................................................................................................................................................................

C. PEMERIKSAAN FISIK PADA BAYI

1. Pemeriksaan Fisik
a. Keadaan Umum
Penampilan keseluruhan : ...............................................................................................................................
Kepala, badan, ekstremitas : ...............................................................................................................................
Tonus otot, tingkat aktifitas : ...............................................................................................................................
Warna kulit dan bibir : ...............................................................................................................................
Tangis bayi : ................................................................................................................................
b. Tanda-tanda vital
Laju napas ( 40-60 x / menit ) : ...............................................................................................................................
Laju jantung ( 120-160 x / menit ) : ...............................................................................................................................
Suhu ( 36,5 – 37,5 0 C ) : ...............................................................................................................................
c. Berat Badan ( 2,5 – 4,0 Kg ) : ...............................................................................................................................
d. Panjang Badan ( 45 – 53 cm ) : ...............................................................................................................................
e. Kepala
Ubun-ubun : ...............................................................................................................................
Sutura, molase : ...............................................................................................................................
Penonjolan / Daerah yang mencekung :
Ukur lingkar kepala : ...............................................................................................................................
f. Mata
Tanda-tanda infeksi yaitu pus : ...............................................................................................................................
g. Telinga
Periksa dalam hubungan letak dengan mata dan kepala : ...............................................................................................................................
h. Hidung dan mulut
Bibir dan palatum : ...............................................................................................................................
Periksa adanya sumbing : ...............................................................................................................................
Refleks hisap, dinilai saat bayi menyusu pada ibunya : ...............................................................................................................................
i. Leher
Pembengkakan : ...............................................................................................................................
Gumpalan : ...............................................................................................................................
j. Dada
Bentuk : ...............................................................................................................................
Puting : ...............................................................................................................................
Bunyi napas : ...............................................................................................................................
Bunyi jantung : ...............................................................................................................................
k. Bahu, lengan, dan tangan
Gerakan normal : ...............................................................................................................................
Jumlah jari : ...............................................................................................................................
Sistem saraf
l. Adanya refleks Moro (rangsangan dengan suara keras
seperti bertepuk tangan) : ...............................................................................................................................
m. Perut
Bentuk : ...............................................................................................................................
Penonjolan sekitar tali pusat saat menangis : ...............................................................................................................................
Perdarahan tali pusat ( tiga pembuluh ) : ...............................................................................................................................
Lembek ( pada saat tidak menangis ) : ...............................................................................................................................
Tonjolan / ada massa : ...............................................................................................................................
n. Kelamin laki-laki
Testis berada dalam skrotum : ...............................................................................................................................
Penis berlubang : ...............................................................................................................................
Kelamin Perempuan
Introitus vagina : ...............................................................................................................................
Orifisium uretra : ...............................................................................................................................
Labia minor dan labia mayora : ...............................................................................................................................
 o. Panggul
Tanda klik : ...............................................................................................................................
p. Tungkai dan kaki
Gerakan normal : ...............................................................................................................................
Tampak normal : ...............................................................................................................................
Jumlah jari : ...............................................................................................................................

q. Punggung dan anus

Pembengkakan / ada cekungan : ...............................................................................................................................
Lubang anus : ...............................................................................................................................
r. Kulit
Verniks caseosa : ...............................................................................................................................
Warna : ...............................................................................................................................
Pembengkakan atau bercak hitam : ...............................................................................................................................
Tanda lahir ? : ...............................................................................................................................
2. Refleks
Refleks Moro : ...............................................................................................................................
Refleks Rooting : ...............................................................................................................................
Refleks Walking : ...............................................................................................................................
Refleks Grahps / Plantat : ...............................................................................................................................
Reflek Sucking : ...............................................................................................................................
Reflek Tonic Neek : ...............................................................................................................................
3. Eliminasi
Miksi : Sudah / Belum Warna : ................................. Tanggal .................................... Pukul .................... WIB
Devekasi : Sudah / Belum Warna : ................................ Tanggal .................................... Pukul .................... WIB
Mekonium : Sudah / Belum Warna : ................................ Tanggal .................................... Pukul .................... WIB

4. Pemeriksaan Laboratorium
HB : ............................ mg / dl HT : ................................ % Bil : ................................ mg / dt
Gbs : ............................ mg / dl Gol. Darah : ...................................... RH : .............................................

Lain-lain : ...............................................................................................................................