UNIVERSITAS NAHDLATUL ULAMA SURABAYA

FAKULTAS KEPERAWATAN DAN KEBIDANAN

PROGRAM STUDI PROFESI NERS
KAMPUS A JL. SMEA NO. 57 SURABAYA (031) 8291920, 8284508, FAX (031) 8298582
KAMPUS B RS. ISLAM JEMURSARI JL. JEMURSARI NO. 51-57 SURABAYA
Website : www.unusa.ac.id Email : info@unusa.ac.id

ASUHAN KEPERAWATAN NEONATUS

Nama Mahasiswa : RS :
NIM : Ruangan :
Tanggal Pengkajian : Jam :

A. IDENTITAS PASIEN
Nama : __________________________
Umur : __________________________
Tanggal Lahir : __________________________
Jenis Kelamin : __________________________
Berat Badan : __________________________
Panjang Badan : __________________________

B. IDENTITAS ORANG TUA

Nama Ibu : Nama Ayah :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat :

C. RIWAYAT KEHAMILAN DAN KELAHIRAN

1. Pranatal
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2. Intranatal
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3. Pascanatal
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D. KELUHAN UTAMA
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E. RIWAYAT PENYAKIT SEKARANG
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F. RIWAYAT PENYAKIT DAHULU

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G. RIWAYAT PENYAKIT KELUARGA

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H. PEMERIKSAAN FISIK
1. Tanda Vital
Suhu badan : ______________ °C
Nadi : ______________ kali/menit
Respirasi : ______________ kali/menit
2. Antropometri
Berat badan : ______________ kg
Panjang badan : ______________ cm
Lingkar kepala : ______________ cm
3. Pemeriksaan Kepala
a) Kelainan kepala
 Caput succedanum  Cephal hematom  Hidrocephalus
 Microcephalus  Anencephalus
b) Lain-lain
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4. Pemeriksaan Mata
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5. Pemeriksaan Telinga
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6. Pemeriksaan Hidung
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7. Pemeriksaan Mulut
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8. Pemeriksaan Leher
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9. Pemeriksaan Dada
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10. Pemeriksaan Abdomen
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11. Pemeriksaan Genitalia
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12. Pemeriksaan Anus
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13. Pemeriksaan Integumen
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14. Pemeriksaan Ekstremitas Atas
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15. Pemeriksaan Ekstremitas Bawah
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I. IMUNISASI
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J. PEMERIKSAAN REFLEKS BAYI

1. Refleks Sucking :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
2. Refleks Graps :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
3. Refleks Tonic Neck :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
4. Refleks Rooting :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
5. Refleks Moro :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
6. Refleks Babinski :  Ada  Tidak ada
Jelaskan: ________________________________________________________________
7. Refleks Menelan :  Ada  Tidak ada
Jelaskan: ________________________________________________________________

K. PENILAIAN APGAR SCORE

Tanda 0 1 2 1 menit 5 menit
Pucat/ Seluruh tubuh
Appearance Badan merah,
seluruhnya kemerah-
(warna kulit) ekstremitas biru
biru merahan
Pulse Tidak ada < 100 kali/ > 100 kali/ menit
 (denyut nadi) menit
Meringis/ Meringis/ batuk/
Tidak ada
Grimace menangis lemah bersin saat
respon thdp
(refleks) ketika stimulasi saluran
stimulasi
distimulasi nafas
Activity Lemah/ Tidak
Sedikit gerakan Gerakan aktif
(tonus otot) ada
Menangis kuat,
Respiration Lemah/tidak
Tidak ada pernapasan baik
(pernapasan) teratur
dan teratur
Total skor

L. DATA TAMBAHAN
1. Laboratorium
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2. Radiologi
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3. Terapi Medis
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4. Ballard Score
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5. Down Score
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