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PROGRAM STUDI S1 KEPERAWATAN SEKOLAH TINGGI ILMU KESEHATAN NAHDLATUL ULAMA TUBAN Kampus A : Jl. P. Diponegoro 17 Tuban (62315) | Telp. (0356) 321287 | Fax. (0356) 333237 | Kampus B : Jl. Letda Sucipto 211 Tuban Telp. ()356)-325789/Fax.(0356) 712572 (62351) | Telp. (0356) 325789 | (0356) 712572 | Website. http://www.stikesnu.com | Email.
[email protected]
PENGKAJIAN NEONATUS DATA BAYI
Nama Bayi Jenis Kelamin : Tanggal Lahir :
:
BB/PB : Apgar Score :
PENGKAJIAN FISIK NEONATUS
1. Reflek Moro (
)
Menggenggam Menggenggam (
2. Tonus Aktifitas a. Aktif ( ) Tenang ( b. Menangis keras ( ) Sulit menangis ( ) 3. Kepala/Leher a. Fontanel Anterior
b. Sutura Sagitalis c. Gambaran Wajah d. Molding
)
) Letargi ( Lemah (
Lunak ( Datar (
) )
5. THT
) )
)
Kejang ( ) Melengking (
Tegas ( ) Menonjol (
Tepat ( ) Terpisah ( Simetris ( )Asimetris ( ) Caput succedanum succedanum ( )
Master your semester with Scribd 4. Mata & The NewBersih York ( Times ) Sekresi ( ) Special offer for students: Only $4.99/month.
Menghisap (
)
)
Cekung (
)
Menjauh (
Cephalohematoma Cephalohematoma
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)
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Tidak ada ( Abnormal (
8. Paru-paru a. Suara nafas kanan kiri sama ( ) b. Bunyi nafas disemua lapang paru
)
d. Respirasi
Ronchi (
) )
Tidak sama ( ) Terdengar ( ) Tidak terdengar ( ) Menurun ( ) ) Rales ( )
Sekres
Spontan ( ) Alat bantu :
9. Jantug a. Bunyi Normal sinud rhythm (NSR) ( ) b. Murmur ( ) Gallop ( c. Waktu pengisian kapiler 10. Ekstrimitas a. Gerakan bebas ( b.
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a. Simetris ( ) Asimetris ( ) b. Retraksi Ada ( ) c. Klavikula normal ( )
c. Suara nafas bersih ( )
Askep Ketuban Pecah Dini Fix
) ROM tervatas (
Nadi Perifer Brakial kanan Brakial Kiri
Keras
)
Frekwensi : )
Tidak terkaji ( Lemah
) Tidak Ada
Femorall kanan Femoral kiri 11. Umbilikus Master your semester with Scribd Normal ( ) Abnormal ( & The NewInflamasi York (Times ) Drainase ( Special offer for students: Only $4.99/month. Jumlah Pembuluh darah (
Ekstrimitas atas
) Normal (
)
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), Sebutka:
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14. Spina Normal (
of 6
)
15. Kulit a. Warna pink ( Sianosis pada
Askep Ketuban Pecah Dini Fix
b. Kemerahan (rash) ( c. Tanda lahir :
16. Suhu a. Lingkungan Penghangat Penghangat radian ( Inkubator ( )
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Abnormal (
)
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Pucat ( ) Kuku ( ) Periorbital (
)
Jaundice ( ) Sirkumoral ( ) Seluruh tubuh ( )
)
)
) )
Pengaturan suhu ( Suhu Ruang ( )
)
Boks terbuka
b. Suhu kulit
DATA IBU Nama Ibu
:
Nama Suami
:
Umur
:
Umur
:
Pendidikan
:
Pendidikan
:
Alamat
:
Alamat
:
RIWAYAT PRANATAL (ANC)
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Askep Ketuban Pecah Dini Fix
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RIWAYAT PERSALINAN (INTRA NATAL)
Awal persalinan
:
Lama persalinan
:
Komplikasi persalinan
:
Terapi yang diberikan
-. Jenis dan jumlah
:
-. Lama pemberian
:
Lama antara ruptur vagina dan saat partus
:
Jumlah cairan ketuban
:
Anestesi yang diberikan
:
Ada/tidak mekonium
:
CATATAN MONITORING FETUS
Indikasi dilakukan monitorint
:
Monitoring internal / eksternal
:
Pola FHR (fetal hearth rate)
:
Analisa gas darah
:
RIWAYAT KELAHIRAN
Lama kala II Cara melahirkan
Pervaginam (
)
Bantuan forceps/vacuum forceps/vacuum extrasi ( Caesar (
)
)
Tempat melahirkan
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Obat-obatan
:
)
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Lama
Askep Ketuban Pecah Dini Fix
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:
Adanya trauma lahir
(
)
Adanya narcosis
(
)
Keluarnya urin
(
)
BAB (
)
Respon Fisiologis atau perilaku yang bermakna :
Prosedur yang dilakukan Aspirasi gaster
(
)
Suksion trakea
(
)
Lain-lain
(
)
RIWAYAT SOSIAL
Struktur Keluarga ( genogram )
Budaya Suku
:
Agama
;
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Hubungan orangtua dan bayi
IBU
TINGKAH LAKU
AYAH
Menyentuh Memeluk Berbicara Berkunjung Memanggil nama Kontak mata
Orang terdekat yang dapat dihubungi : Orang tua berespon terhadap penyakit
ya (
)
tidak (
ya (
)
)
Respon :
Orang tua berespon terhadap hospitalisasi
tidak (
)
Respon :
Anak lain : Jenis Kelamin Anak
Riwayat Persalinan
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Data tambahan :
Riwayat Imunisasi
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