ASKEP BBL
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Transcript of ASKEP BBL
ASUHAN KEPERAWATAN NEONATAL
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PENGKAJIAN
Tanggal MRS/Jam :
Tanggal Pengkajian/Jam :
Tempat :
A. DATA SUBYEKTIF
1. Identitas
Nama Bayi :...............................................................................................................................
Tanggal/Jam Lahir :...............................................................................................................................
Jenis Kelamin :................................................................................................................................
Umur :...............................................................................................................................
Dx Medis :................................................................................................................................
2. Keluhan Utama
a) Saat MRS :……………..............................................................................................................
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b) Saat Pengkajian :………………..........................................................................................................
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3. Identitas Orang Tua
4. Riwayat Prenatal
- Kehamilan ke :....................................................................................................................
Ayah Ibu
Nama
Umur
Suku/Bangsa
Agama
Pendidikan
Pekerjaan
Alamat
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- Tempat ANC :....................................................................................................................
- Imunisasi TT :.....................................................................................................................
- Obat-Obatan yang pernah diminum selama hamil :..........................................................................
- Penerimaan Ibu/Keluarga Terhadap kehamilan :.........................................................................
- Masalah yang pernah dialami ibu saat hamil :...........................................................................
4. Riwayat IntraNatal
- Persalinan ke :..........................................................................................................
- Tempat dan penolong persalinan :..........................................................................................................
- Masalah saat persalinan :...........................................................................................................
- Jenis Persalinan :............................................................................................................
- Lama persalinan :.............................................................................................................
- Keadaan bayi saat lahir :.............................................................................................................
- Segera menangis/tidak :..............................................................................................................
5. Riwayat Natal
- Keadaan bayi baru lahir
- Lahir tanggal : .....................................,jam..........................................................
- Masa gestasi : ........................................ minggu
- BB/PB lahir :.........................gram, ......................cm
- Nilai APGAR : 1 menit/5menit/10 menit/2 jam:
No Kriteria 1 menit 5 menit 10 menit 2 jam
1 Denyut Jantung
2 Usaha nafas
3 Tonus otot
4 Reflek
5 Warna kulit
TOTAL
6. Pola Fungsi kesehatan
Kebutuhan Dasar Saat MRS Saat Pengkajian
1. Cairan & Makanan
2. Eliminasi
3. Istirahat & Tidur
4. Personal hygiene
5. Aktivitas
7. Status Imunisasi :.......................................................................................................................................
B. DATA OBJEKTIF
1. Pemeriksaan Umum
a. Keadaan umum : ......................................................................................................................................
b. kesadaran : ......................................................................................................................................
c. Tanda vital
Nadi :.......................................................................................................................................
Pernafasan :.....................................................................................................................................
Suhu :.......................................................................................................................................
2. Pemeriksaan Antropometri
BB :....................................................................................................................................................
PB :....................................................................................................................................................:
LK :....................................................................................................................................................
LD .....................................................................................................................................................:
LLA :....................................................................................................................................................
2. Pemeriksaan Fisik
Kepala : ...................................................................................................................................................
Muka :....................................................................................................................................................
Ubun-ubun : ....................................................................................................................................................
Mata : ....................................................................................................................................................
Hidung : ....................................................................................................................................................
Telinga : ....................................................................................................................................................
Mulut : ....................................................................................................................................................
Leher : ....................................................................................................................................................
Dada : ....................................................................................................................................................
Tali pusat : ....................................................................................................................................................
Abdomen : ....................................................................................................................................................
Punggung : ....................................................................................................................................................
Ekstermitas : ....................................................................................................................................................
Genitalia : ....................................................................................................................................................
Anus : ....................................................................................................................................................
3. Pemeriksaan Neurologis
Moro : ....................................................................................................................................................
Rooting : ....................................................................................................................................................
Sucking : ....................................................................................................................................................
Swallowing : ....................................................................................................................................................
Walking : ....................................................................................................................................................
Graphs : ....................................................................................................................................................
Tonicneck : ....................................................................................................................................................
Burning : ....................................................................................................................................................
5. Pemeriksaan Penunjang
a. Pemeriksaan Laboratorium
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b. Terapi
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B. ANALISA DATA
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No Tanggal / Jam Analisa Data Masalah Etiologi
C. DIAGNOSA KEPERAWATAN
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D. INTERVENSI.....................................................................................................................................................................................................
NO TANGGAL/JAM
KRITERIA HASIL INTERVENSI RASIONAL
NO TANGGAL/JAM
KRITERIA HASIL INTERVENSI RASIONAL
E. IMPLEMENTASI..............................................................................................................................................................................................
NO TANGGAL/JAM IMPLEMENTASI
NO TANGGAL/JAM IMPLEMENTASI
F. EVALUASI
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NO TANGGAL/JAM EVALUASI
NO TANGGAL/JAM EVALUASI