Format pengkajian keperawatan Bayi Baru Lahir
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keperawatan
Transcript of Format pengkajian keperawatan Bayi Baru Lahir
Program Studi Ilmu Keperawatan A Tahun 2011
LAPORAN ASUHAN KEPERAWATAN PADA Bayi .........
DENGAN ........................................................... DI .......................................................
TANGGAL ……………………………………
A. PENGKAJIAN
I. IDENTITAS
Nama :
Umur :
Jenis Kelamin :
Pekerjaan :
Nama orang tua :
Tanggal MRS :
Tanggal pengkajian :
Sumber informasi :
No CM. :
II. RIWAYAT KELAHIRAN YANG LALU
No. Tahun kelahiran Sex BB lahir Keadaan bayi Komplikasi Jenis persalinan Ket
III. RIWAYAT PERSALINAN
BB/TB ibu: ...........kg/...........cm Persalinan di ................................
Keadaan umum ibu .................... Tanda Vital .................................................................
Jenis persalinan .................... Proses Persalinan ............................................................
Kala I ....... jam Indikasi ...................................................... Kala II ...........menit
Komplikasi persalinan ibu ............................... Janin..............................................
Lamanya ketuban pecah ........................................... Kondisi ketuban ..........................
Praktik Profesi Keperawatan Maternitas
Program Studi Ilmu Keperawatan A Tahun 2011
IV. KEADAAN BAYI SAAT LAHIR
Lahir tanggal: ……………………………. Jam…………………… sex……………
Kelahiran: tunggal/gemeli
Praktik Profesi Keperawatan Maternitas
Program Studi Ilmu Keperawatan A Tahun 2011
Nilai APGAR
TandaNilai
Jumlah0 1 2
Appearance color (warnakulit)
Pucat/biru Tubuh kemerahan, tangan dankaki biru
Kemerahan seluruh tubuh
Pulse(denyut jantung)
Tidak ada <100 >100
Grimace(reaksi terhadap
rangsangan)
Tidak ada Sedikit gerakan mimik Menangis, batuk, bersin
Activity(tonus otot)
Lumpuh Ekstremitas fleksi sedikit Gerakan aktif
Respiratory(usaha napas)
Tidak ada Lemah tidak teratur Menangis kuat
V. PEMERIKSAAN FISIK
Berat badan : ...............................................
Panjang badan : ...............................................
Suhu : ...............................................
Lingkar kepala : ...............................................
Lingkar dada : ...............................................
Lingkar perut : ...............................................
Tubuh:
Warna : ...............................................
Program Studi Ilmu Keperawatan A Tahun 2011
Lanugo : ...............................................
Vernix : ...............................................
Head to Toe :
a. Kepala Wajah
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Mata: ...............................................................................................................................
Telinga: ...........................................................................................................................
Hidung: ...........................................................................................................................
Mulut: ..............................................................................................................................
b. Leher
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c. Dada
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Program Studi Ilmu Keperawatan A Tahun 2011
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d. Abdomen
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..........................................................................................................................................Keadaan tali pusat ...............................................................................................................................................................................................................................................................................................................................................................................................
e. Punggung
Keadaan punggung ..........................................................................................................
Program Studi Ilmu Keperawatan A Tahun 2011
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..........................................................................................................................................Fleksibilitas ...............................................................................................................................................................................................................................................................Tulang punggung ......................................................................................................................................................................................................................................................Kelainan ....................................................................................................................................................................................................................................................................
f. Genetalia dan anus
Mekonium .................................................................................................................................................................................................................................................................Kelainan ....................................................................................................................................................................................................................................................................
g. Ekstremitas
Atas: ..........................................................................................................................................................................................................................................................................Bawah : .....................................................................................................................................................................................................................................................................Kelainan: ...................................................................................................................................................................................................................................................................Pergerakan: ...............................................................................................................................................................................................................................................................
VI. STATUS NEUROLOGI
Pemeriksaan reflek
Refleks moro : ..................
Program Studi Ilmu Keperawatan A Tahun 2011
Refleks rooting : ..................Sucking refleks : ..................Ballard score : ..................
VII. PEMERIKSAAN PENUNJANG
Pemeriksaan Laboratorium : ...............................................................................................................................................................................................................................................................................................................................................................................................Radiologi : ..........................................................................................................................................................................................................................................................................................................................................................................................................................
VIII. Diagnosa Medis
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IX. Pengobatan
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B. ANALISA DATA DAN DIAGNOSA KEPERAWATAN
NO DATA ETIOLOGI MASALAH
Program Studi Ilmu Keperawatan A Tahun 2011
DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS:..........................................................................................................................................................................................................................................................................................................................................................................
Program Studi Ilmu Keperawatan A Tahun 2011
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Program Studi Ilmu Keperawatan A Tahun 2011
C.
D. RENCANA KEPERAWATAN
NO. DX.RENCANA KEPERAWATAN
Tujuan Intervensi Rasional
Program Studi Ilmu Keperawatan A Tahun 2011
E.
F. IMPLEMENTASI
Tanggal/jam No.Dx IMPLEMENTASI Evaluasi/respon klien Paraf/nama
Program Studi Ilmu Keperawatan A Tahun 2011
Program Studi Ilmu Keperawatan A Tahun 2011
G. EVALUASI/CATATAN PERKEMBANGAN
Tanggal/jam No. Dx. Evaluasi
Program Studi Ilmu Keperawatan A Tahun 2011
Program Studi Ilmu Keperawatan A Tahun 2011
Denpasar, ___________________ 2011
Mengetahui,
Clinical Instructor/ CI Mahasiswa
(Nym Admini, Amd Keb) (Putu Ayu Lestarini, S. Kep)
NIP: NIM:
Clinical Teacher/CT
(Nengah Runiari, S.Kep, S.Pd, M.Kep, Sp.Mat)
NIP:
Praktik Profesi Keperawatan Maternitas
