FORMAT PENGKAJIAN NEONATUS rang rR: a ABR Tam Mask ORAS. Earn Seni Agee Be No 3604 Jam Pengkajian ie _ Diiagnoea Masuk ; AOS. -Ruangan Rawat Inap Hed, 1. IDENTITAS PASTEN Name Bg. Rch Penanggungjawad Vor gohae (isi bila penanggung jab bukan ‘Tanggal abir |, 9. JU 2004 cree, Sulwtangss | are Nes ‘Agama Islam Alarat Alamat i, Brbetome ML IDENTITAS ORANG TUA “Ayah | Tou x ‘Nama \% Ht ‘Nama Nyt nur | 4a th | ume 3¢-fahun Solavtangss [Bayar | suka Dagger Aeama |Ietam so Islam Peniian soa Pein A Pekerjaan | Soarts Peejean ter ‘Alamat | Dl Pr-foeteme | Alamat Th Or-foekomo, IIL.Riwayat Kesehatan Neonatus 6 36. “1900.9. Apgar score: 1”. Usia gestasi: Berat badan: 32cm, LK: Lia: Kompikasi persatinan: Tidak ada (...) a. Aspirasi mekonium (..) Denyut jantung janin abnormal (....) Masalah lain. Prolaps tall pusalllitan tai pusat (. Ketuban pecah dini (..¢] berapa jam: 3len.... 49¢ ‘Ada (..5 e. Rooting (7-6 tidak fi aaah b. Menangis eras (...) (<7 Melengking (....) menangis (....) Lemah Sulit . Gambaran wajah: simetris (<< asismetis (...) () Cekung (...) . Molding (od caput b. Sutura sagitalis: tepat (J succedaneum ey Terpisah (...) menjauh (....) _ chepalhematom (...) Tumpang tind (...) 4. Mata: a. Bersih (. 6 © gangguan pernapasan berat 8. Jantung a. Irma jantung: teratur (% 20m ( gas (...) datar tidak teraba ( () kemibung (<7 e. Kelai e. Lingkar perut...28..0m 14.Umbitikus, 2. Normal (..““Fabnormal (....) b. Inflamas|(.....) drainage (....) 12.Ekstremitas: . Gerakan bebas_(‘ |h g MATURITAS FISIK NEUROMUSKULAR, BALLARD SCORE,bara Foxus =. Ne. pagen molten Aluhiten cater barns mndiles cee ‘ep 2 aera onary =. Pay lahiim ab beret. (960 gr. coc lllla, Gerkar: 3a nega “pats EB BEERS: Oh HY Flas 6, Ox. Blonde = Pole. mage opal Son cenalerl» BA 5ax/imnt rama leerkin: = Spor! 38% = Terdapat rekeake: Sindhig Sask Hubcee biti berg = Terdeagah perrecle expen. — tar 7 adehk = Abeal tribe Lirgin ar pocak Madd periper kmah Nor =H. 3.10.2 a ~ Leukorie 74 x los ~Has| AeD pes Fae ploy : 32.2 ad AamereeBe. 2. Aguchie a9 a1 Precepiee, Si Aor... Peetrsinnivg, NIM, 20722092000"ANALISA DATA NAMA: Py hg RUANG 3: Necw NO.REG =: Jou. KK.x TANGGAL § :02 /08 No [— Data ENIOLOGI MASALAITRE- 1 [pss ~ ee Gangguon Nenklan oa ¥ penton (0-c004 ~ Bert boyt Woo gr Obot 7 pernageuan -Una Gertae: ee lemahy WR pa " 4 Fes Opies 211% Or 81h Day benore poy = ola mapas cpat Ban dongtal ena | ~ Pe: Sax /ir LpOs *98% ¥ ~ Tirbagat rete diddy dada os | - Terdapat * | ne peempucn cipig | oO velar | [-TerBopat perede apma Spntan 3 [Ors - (Princo Ghabttne| PUPA erfee Alveolar~ Tidak efekhe - pe bibir berwig f * (0.0004) ~ cer > adobe a | eter bork = Attn] Heaton Diigin olen | meron bt pucat - | a eee = Nad pertper emer | ~ Hh: 10.2 9/4 faeaee ergacgp | + | Mipebreme, | | + | Pras peripe tle eeekheANALISA DATA sata: Barty mua: New ROlMEC 3 or weve Titeaa | Saroe NO DATA _ETIOLOGT “MASALAH KEP. 3- | Os: = Pembenkiker ented’, Pesiko Inger fo | Ino Peg ben mndopatton | bh pa (0.042) vaen heginp- | er inn rls ~Frpatana, pap : Pepacany NET Dag teen bibth - Bele role | ~ letkowt 14 % 10% . | Prriko Inger |RUMUSAN DIAGNOSA KEPERAWATAN ‘DINGNOSA KEPERAWATAN TANGGAL DITEMUK: TANGGAT. TERATASI Gangquan Venklax: Jpenten (poood) 2 Auchir Pergub perfor Tidak bpekie (0.2005) & Apuchur dont Rieike Ingebsr (0.0149) 2 Aguetur PARAF| are 5 face Ar Aniel.‘uy saw oped (59 wununa pala Urleionund Ung Crveqind Hagin by vedou Mure 449 woounblnd “| 9 eaelload Cay SE) @ > vofiduma he hinge Sywonsy “pad ee Oey a] ic) equine ~i7 {dey wosbdnd - geeflog rape ofa wergimaing "Peled AYO TS oo, aay pume -sdurd dad sind weap expand ive afdayg “wel 9 x) “ues! Iya WPL enpup amp rrand unjreraindry guns extra Yop! srdurd amdnd) ve/afe |-e (3) umn sees serge, nung 4240 crooner «9 tasy eta aye rl (3) Gun ‘udage serbaqe searyer Vepcey © ay mp 44 | medias Copel, Ung equanp iege YN TE) Bsyny Ir ygyann asian sedi shed Ung * Gouin) egry “we ‘Yerrpred ILO Hay wach any Mager Usp road, eaejendy Jee 1 Medd wornucting aire typing Lagm ae 4ep4Ry | siqquin 69 | ve/ 9/z| +1 Tas iar NVIVAVEED l 2x ue 20x ef 'YSONDVIG [TVD9NVI. [ON BH-X TEE | “DA 'ON ron? 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Ae \03 Mimenifor satires: ole: on me | oo: ee [-$p0. 28% 15 rundingarben toe mapa 2 Mince tangan Lebthin Sun Seba bors tek. 21 Munwitea érbulaty perifer | 3-1 Mumonitor- tank gah tnjeke: | beEVALUASI RUANG =: Nicu ‘CATATAN PERKEMBANGAN GOA) Parat 2/g31 | Gy. Vinklaw [es — a pee: GIx/i « nay + dargkal Tirhopat Aika tay tobe. Ab Trdupat penode apnea. Rat | ‘Teepaeacy PAP | Peep Fo ae | Flos & & Blonde Spo. 99% Fare napar Vetibulen - Tidak terbapab Rumbatan Plan napa. lA: Pamish 9 Verklera Gone OI loataa: |p: Lankan Inkrving | | ee fick, trims, bBbleman, Lon pays Peppa | | 12 Mentor Sang eumlaan jlo repas. 1:3 Mimenther Salureap: Or | Bfai| Pere pore 2 ~ Tek Gprkhe | ©! ~ Ned parter kinerh, |- err adh ~ Ker! Arig, Bn pucak | ~ Tergor ik, muttorg brig | A: Pracley pereian: perife telak epehhye belom rekon: | P* Lenpitkan Iplervene | 2! Perthea. srbulas- perypar | 2.2 Monier paraé, tmurahon, nye eet, pt thetrcnitan, 28 labitor pineegahan riysks ANEVALUASI Nama RUANG Nokes. = Te | Dingo CCATATAN PERKEMBANGAN GOAPy i ape Keperawatan | | par | Pesito fee ] Inpeker ° | | | “nak keblapel burgink Ln bimereshan Tidak bbtpat panda ogpale thpeke T7387 A: Paalah Pretke Ingekar tikak terjabd> Ps Lempitkan Infevens- 31 Monitor femBa Fepula inguke 3.2 Qe tanger. 33 Datla penguryang