FORMAT PENGKAJIAN BAYI BARU LAHIR (BBLR)
PENGKAJIAN
BAYI BARU LAHIR
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Nama
Mahasiswa
Nama
Ayah-Ibu
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:
...............................................
:
...............................................
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Tanggal
Pengkajian
Ruangan
/ RS
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:
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:
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Alamat
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:
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:
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Riwayat
Kelahiran Yang Lalu
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No
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Tahun
Kelahiran
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Jenis
Kelamin
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BB
Lahir
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Keadaan
Bayi
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Komplikasi
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Jenis
persalinan
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Ket
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Status
Gravida
G ............ P ............ A
............ H ............. UK ............. minggu, presentasi bayi ...........................................................
Pemeriksaan antenatal: teratur / tidak
teratur
Komplikasi antenatal:
......................................................................................................................................................
Riwayat
Persalinan
BB/TB ibu: .................... kg/
.................... cm. Persalinan di
..........................................................................................
Pengkajian
Fisik
Umur .............................. hari
.............................. jam
BB .............................. PB
.............................. suhu .............................. LK
.............................. LD .............................
LLA .............................. lingkar
perut ..............................
Kepala
Bentuk kepala ( ) bulat ( ) molding ( ) lain-lain
( ) kaput ( ) chepalhematome
Ubun-ubun besar
....................................... kecil ........................................
sutura ................................................
Mata Posisi................................
(
) kotoran ( ) perdarahan
Telinga Posisi
............................................................... bentuk
.......................................................................
( ) lubang telinga
........................................... (
) keluaran ............................................................
Mulut ( ) simetris ( ) pallatum mole ( ) gigi
Hidung ( ) lubang hidung ( ) keluaran ( ) pernapsan cuping hidung
Leher ( ) bulat ( ) lain-lain
Tubuh
Warna ( ) pink ( ) pucat ( ) sianosis ( ) kuning
Pergerakan ( ) aktif ( ) kurang
Dada ( ) asimetris ( ) retraksi ( ) seesaw
Jantung dan Paru ( ) normal ( ) ngorok ( ) lain-lain
Pernapasan .................... x/menit
Denyut jantung .............. x/menit
Perut ( ) lembek ( ) kembung ( ) benjolan
Bising
usus .......... x/menit
Lanugo
..........................................................
Verniks
.........................................................
Mekonium
....................................................
Punggung
Keadaan punggung ( ) simetris ( ) asimetris ( ) pilonoidal dimple
Fleksibilitas tinang pinggung ( ) normal ( ) kelainan
Genetalia
Laki-laki ( ) normal ( ) hypospadius ( )
epispadius ( ) testis belum turun
( ) lain-lain, jelaskan: ........................................................................................................................
Perempuan
Labia minora ( ) menonjol (
) tertutup labia mayora ( ) keluaran ( ) kelainan
Jelaskan: ..............................................................................................................................................
Status
Neurologi
Refleks (dinilai semua) ( ) tendon ( ) moro ( ) rotting
( ) menghisap ( ) babinski ( ) menggenggam
( ) menangis ( ) berjalan ( ) tonus leher
Nutrisi
Jenis makanan ( ) ASI ( ) PASI ( ) lain-lainEliminasi
BAB pertama: tgl/jam:
.....................................................................................................................................................
BAK pertama: tgl/jam: .....................................................................................................................................................
Ekstremitas
Jari tangan ( ) normal ( ) kelainan
Jari kaki ( ) normal ( ) kelainan
Pergerakan ( ) tidak aktif ( )
asimetris ( ) tremor ( ) rotasi paha
Nadi ( ) brachial ( ) femoral
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Garis telapak kaki
............................................................................................................................................................
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Posisi
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Kaki
Tangan
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Data
lain yang menunjang (lab, psikososial, dll):
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Kesimpulan:
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Ket:
BBL yang dikaji berusia ≤ 24 jam
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