Riwayat kesehatan keluarga : ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
5.
Genogram
Keterangan: : laki-laki/perempuan : laki-laki/perempuan meninggal : klien/ pasien : garis perkawinan : garis keturunan : tinggal serumah
6.
Riwayat sosial: a. Sistem pendukung keluarga ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
b. Hubungan orang tua dengan bayi ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ c. Lingkungan rumah ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ d. Problem sosial yang penting ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ III. PEMERIKSAAN FISIK (Head to toe)
1.
Keadaan umum : _____________
2.
Kesadaran
: _____________
3.
Vital Sign
:
Suhu : _____________
Nadi : _____________
RR
: _____________
BB
: ____________________________________________
PB
: ____________________________________________
Lingkar kepala : ____________________________________________
4.
Refleks a. Reflek moro : ______________________________________________________ b. Reflek menggenggam: _______________________________________________ c. Reflek menghisap: __________________________________________________
Kekuatan menangis _________________________________________________________________________________ _________________________________________________________________________________
7.
8.
Kepala : ____________________________________________________. a.
11. Perkembangan a. Menangis bila nyaman b. Membuat suara tenggorokan pelan c. Memandang wajah dengan sungguh-sungguh d. Mengeluarkan suara e. Berespon secara berbeda terhadap objek berbeda f. Dapat tersenyum g. Bereaksi terhadap sumber cahaya h. Mengoceh dan memberi reaksi pada suara i. Membalas senyuman
g. Status cairan ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
h. Aktivitas
:
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ i. Istirahat dan tidur ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ j. Tindakan keperawatan yang telah dilakukan ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
