Format Pengkajian Neonatus

PENGKAJIAN FISIK NEONATUS

Nama Mahasiswa NIM Tanggal Pegkajian

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I.	IDENTITAS KLIEN
	Nama/Inisial Umur Tanggal Lahir Jenis Kelamin Agama MRS No. Register Diagnosa Medis	: ........................................ : ........................................ : ........................................ : ........................................ : ........................................ : ........................................ : ........................................ : ........................................	Penanggung Jawab Nama Ayah/Ibu Pekerjaan Ayah/Ibu Pendidikan Ayah/Ibu Umur Ayah/Ibu Suku Ayah/Ibu Agama Alamat		: ............................................... : ............................................... : ............................................... : ............................................... : ............................................... : ............................................... : ............................................... : ...............................................

1.       Reflek

Moro (   )   Genggaman Tangan (   )   Genggaman Plantar (   )   Startle (   )   Pupil (   )   Kornea (   )

Glabella (   )   Sucking (   ) : Kuat / Lemah,   Rooting (   )   Ekstrusi (   )   Yawning (   )   Gag (   )

Neck Righting (   )   Otolith-Righting (   )   Stepping (   )   Galant (   )

2.       Tonus/Aktifitas

a.       Aktif (   )   Tenang (   )   Letargi (   )   Kejang (   )

b.       Menangis Keras (   )   Lemah (   )   Melengking (   )   Otolith-Right (   )

3.       Kepala/Leher

a.       Fontanel anterior Fontanel posterior b.       Sutura sagitalis batas c.       Gambaran wajah d.       Molding e.       Leher

Lunak (   )   Tegas (   )   datar (   )   menonjol (   )   cekung (   ) menutup usia: ........................................................... Lunak (   )   Tegas (   )   datar (   )   menonjol (   )   cekung (   ) menutup usia: ........................................................... Tegas (   )   terpisah (   )   menjauh (   )   tumpang tindih (   )   simetris (   )   asimetris (   ) Caput succedaneum (   )   Cephalhematoma (   )   makrocephal (   ) mikrocephal (   )   anecephaly (   ) simetris (   )   asimetris (   )   pergerakan bebas (   ) pembesaran kelenjar (   )   peningkatan JVP (   )   kaku kuduk (   )

4.       Mata

Bersih (   )   sekresi : ada (   )   tidak ada (   )   simetris (   )   asimetris (   )

Jarak interkantus _______________ Sklera : _______________ konjungtiva : ______________

Strabismus (   )   katarak congenital (   )

5.       Telinga & Hidung

a.       Telinga b.       Hidung

Normal (   )   Abnormal (   )   letak pinna : ________________ Simetris (   )   asimetris (   )   sekresi (   )   napas cuping hidung (   )

6.       Wajah

a.       Bentuk wajah simetris/normal (   )   abnormal (   )

b.       Bibir sumbing (   )    Sumbing langit-langit/palatum (   )

7.       Abdomen

a.       Lunak (   )   Tegas (   )   datar (   )   kembung (   )

b.       Lingkar perut ............... cm

c.       Liver: teraba (   )   Kurang dari 2 cm (   )   Lebih dari 2 cm (   )   Tidak teraba (   )

8.       Toraks / dada

a.       Bentuk simetris (   )   asimetris (   )   pigeon chest (   )   barrel chest (   )   funnel chest (   )

b.       Pergerakan: retraksi interkostal (   )   simetris (   )

c.       Irama napas: reguler (   )   ireguler (   )   dyspneu (   )   apneu (   )  

d.       Bunyi napas: vesikuler (   )   ronchi (   )   wheezing (   )   rales (   )

e.       Respirasi spontan (   )

Alat bantu napas: oksigen mask (   )   nasal kanul (   )   konsentrasi  : ______ liter/menit

Frekuensi pernapasan: ________________

f.        Irama jantung: reguler (   )   ireguler (   )

g.       Bunyi Normal Sinus Rhythm (NSR): (   )

Frekuensi: ________________

h.       Murmur (   )   PMI (   ); lokasi: _______________

i.        Waktu pengisian kapiler (CRT) : ______________

j.        Denyut nadi: ______________

9.       Ekstremitas

Gerakan bebas (   )   ROM terbatas (   )   tidak terkaji (   )

Ekstremitas atas normal (   )   abnormal (   ), sebutkan : ____________________

Ekstremitas bawah normal (   )   abnormal (   ), sebutkan : ____________________

Panggul normal (   )   abnormal (   )   tidak terkaji (   )

10.   Umbilikus

Normal (   )   abnormal (   )   inflamasi (   )   drainase (   )

11.   Genetal

Perempuan normal (   )   Laki-laki normal (   )   abnormal (   )

Sebutkan : ___________________

12.   Anus Paten (   )   Imperforata (   )

13.   Spina Normal (   )   abnormal (   )

Sebutkan : _____________________

14.   Kulit

a.       Warna pink (   )   pucat (   )   jaundice (   )   sianosis pada kuku (   )   sirkumoral (   )

periorbital (   )   seluruh tubuh (   )

b.       Kemerahan/rash (   )

c.       Tanda lahir (   ) ; sebutkan : _________________

d.       Turgor kulit: elastis (   )   tidak elastis (   )   edema (   )   lanugo (   )

e.       Suhu

1)      Lingkungan

Penghangat radian (   )   pengatur suhu (   )

inkubator (   )   suhu ruang (   )   boks terbuka (   )

2)      Suhu kulit : __________________

15.   Pemeriksaan lain-lain: ...........................................................................................................................................

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