PENGKAJIAN AWAL MEDIS DAN Nama:

KEPERAWATAN/KEBIDANAN BAYI BARU LAHIR

Tgl Lahir: L/P

PUSKESMAS No. Rm:

LENDIWACU
Alamat:
Tgl: ........./......../............ Jam:..................WITA Ruangan:
I. Pengkajian Keperawatan/ Kebidanan
Diagnosa medik:
Tiba di ruangan (tgl/jam):
Anamnesa
Keluhan Utama:

Riwayat Kesehatan
Riwayat Kehamilan :
Umur Kehamilan: ________________________________________________________________________
Penolong :
ANC : _________________________________________________________________________
TT : _________________________________________________________________________
Kenaikan BB Ibu : _________________________________________________________________________
Penyakit Persalinan:
Kala I :
Kala II :
DJJ : ____________x/mnt Ketuban pecah : ________ WITA Warna : □ Jernih □ Keruh □ HIjau
Jenis Persalinan : □ Normal □ Vacuum □ Forcep □ Sungsang □ Sectio Caesaria
Eliminasi : BAK : BAB :
Riwayat Penyakit dalam keluarga:
II. Pengkajian Medis
Faktor Risiko Infeksi III. PEMERIKSAAN FISIK
Mayor □ Minor □ HR :
O
□ Ibu demam (>38 C) □ KPD > 12 jam RR :
□ KPD > 24 jam □ Asfiksia (1’<5,5’<7) S:
□ Korioamnionitis □ BB:SR (< 1500 gr) Spo2 :
□ Fetal distress □ UK < 37 minggu BBL/PBL :
DJJ > 160 x/mnt □ Gemeli LK/LD :
/ DJJ < 100 x/mnt □ Keputihan
□ Ketuban hijau □ Tersangka ISK
□ Ibu deman (> 37,5oC)
Kepala :
Mata :
Hidung :
Telinga :
Mulut :
Leher :
Dada :
Abdomen :
Genitalia
Anus :
Ekstremitas :
APGAR SCORE
1’ 5’ 10’ 15’
Appearance
Pulse
Grimace
Activity
Respiration __________________________________
TOTAL
 NEW BALLARD SCORE
NEUROMUSCULAR MATURITY

PHYSICAL MATURITY

SCORE RECORD
PHYSICAL
MATURITY SIGN
SCORE
-1 0 1 2 3 4 5 HERE
sticky gelatinous superficial cracking parchment leathery
smooth pink
SKIN friable red peeling & / or pale areas deep cracking cracked
visible veins
transparent translucent rash, few rare veins no vessels wrinkled
veins

LANUGO none sparse abundant thinning bald areas mostly bald

heel-toe 40– anterior

>50 mm faint creases creases over
PLANTAR 50 mm: -1 transverse
no crease red marks ant. 2/3 entire sole
SURFACE < 40 mm: -2 crease only

barely flat areola stippled areola raised areola full areola

BREAST imperceptible
perceptible no bud 1–2 mm bud 3–4 mm bud 5–10 mm
bud
lids fused lids open sl. curved well-curved
pinna; soft; pinna; soft but formed & thick cartilage
EYE / EAR loosely: -1 pinna flat
stays slow recoil firm instant ear stiff
tightly: -2 ready recoil
recoil
folded
testes in testes testes
GENITALS scrotum flat, scrotum testes down
upper descending pendulous
(Male) smooth empty faint good rugae
canal rare few rugae deep rugae
rugae rugae
clitoris prominent prominent majora & majora
GENITALS clitoris & majora large
prominent clitoris & enlarging minora equally cover
(Female) minora small
& labia flat small labia minora prominent clitoris &
minora minora
Reference TOTAL PHYSICAL
Ballard JL, Khoury JC, Wedig K, et al: New Ballard Score, expanded to include extremely premature infants.
J Pediatr 1991; 119:417–423. Reprinted by permission of Dr Ballard and Mosby—Year Book, Inc. MATURITY SCORE

Score -10 -5 0 5 10 15 20 25 30 35 40 45 50
Weeks 20 22 24 26 28 30 32 34 36 38 40 42 44
 III. Pemeriksaan Penunjang

Laboratorium: Radiologi:
IV. ASSESSMENT

V. Rencana Asuhan Keperawatan/Kebidanan:

Tanggal/Jam Atasan langsung Bidan

Selesai Pengkajian

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