ASUHAN KEBIDANAN PADA ANAK
NO. REGISTER: …………………………
MASUK RS TANGGAL, JAM : ……………………………………………………...
DIRAWAT DI RUANG :
...................................................................................
I.
PENGKAJIAN
DATA, Oleh:..........................................Tanggal/Jam:
.......................
A. Biodata
1. Nama bayi : ..........................................
2. Tanggal lahir : ........................ jam ..........
3. Nama Ibu : .......................................... Ayah .......................................
4. Umur :
.......................................... .................................................
5. Agama : .......................................... .................................................
6. Suku/bangsa : .......................................... .................................................
7. Pendidikan : .......................................... .................................................
8. Pekerjaan : .......................................... .................................................
9. Alamat : .......................................... .................................................
B. Data Subjektif
1. Riwayat kehamilan
G ........ P .......... A .......... Ah
...............
Umur kehamilan :
...................................................................................
Riwayat ANC :
teratur/tidak, ......... kali, di ..................... oleh .........
Imunisasi TT :
.......... kali
TT 1 tanggal .................., TT 2 tanggal
.....................
Kenaikan BB : .......... kg
Keluhan :
...................................................................................
Penyakit selama hamil
...................................................................................
Kebiasaan
·
Makan :
·
Obat/jamu :
·
Merokok
:
Komplikasi
·
Ibu :
·
Janin
:
2. Riwayat persalinan
Kala II mulai tanggal : ...............................
jam ................
DJJ :
TBJ :
Ketuban pecah :
lama..................... jam, warna ..................................
Vaskularisasi :
………………………………………………...........
Caput succedaneum :
...................................................................................
Lahir seluruhnya : tanggal .........................jam
.............
Jenis persalinan : spontan / tindakan.....................................................
Atas indikasi
.............................................................
Penolong : .................................. di
............................................
PB/BB lahir :
...................................................................................
Lama persalinan :
Kala I ....................... jam ................... menit
Kala II ...................... jam
................... menit
3. Keadaan bayi baru lahir
Lahir tanggal.......................................
jam ....................................................
Masa gestasi : ................................... minggu
BB/PB lahir :................................................................................................
Nilai APGAR : 1 menit/5 menit/10 menit/2 jam: ....... /........ /.......
/........
|
No
|
Kriteria
|
1 menit
|
5 menit
|
10 menit
|
2 jam
|
|
1
|
Denyut Jantung
|
|
|
|
|
|
2
|
Usaha nafas
|
|
|
|
|
|
3
|
Tonus otot
|
|
|
|
|
|
4
|
Reflek
|
|
|
|
|
|
5
|
Warna kulit
|
|
|
|
|
|
|
TOTAL
|
|
|
|
|
Cacat bawaan : ...............................................................................................
Resusitasi :
Penghisapan lendir : ya/tidak
Ambu bag :
ya/tidak
Massase jantung : ya/tidak
C. Data Objektif
1. Pemeriksaan Umum
a. Keadaan umum : ...................................................................................
b. Tanda vital
Tekanan darah :
...................................................................................
Nadi :
...................................................................................
Pernafasan :
...................................................................................
Suhu :
...................................................................................
c. BB sekarang : ...................................................................................
2. Pemeriksaan Fisik
a. Kepala :
...................................................................................
b. Muka :
...................................................................................
c. Ubun-ubun :
...................................................................................
d. Mata :
...................................................................................
e. Hidung :
...................................................................................
f.
Telinga
:
...................................................................................
g. Mulut :
...................................................................................
h. Leher
:
...................................................................................
i.
Dada :
...................................................................................
j.
Tali
pusat :
...................................................................................
k. Abdomen : ...................................................................................
l.
Punggung :
...................................................................................
m. Ekstremitas :
...................................................................................
n. Genetalia :
...................................................................................
o. Anus :
...................................................................................
3. Reflek : Moro : ...........................................................
Rooting :
...........................................................
Walking :
...........................................................
Graphs :
...........................................................
Sucking :
...........................................................
Tonicneck :
...........................................................
4. Antropometri : LK :
.................. cm
LD : .................. cm
LK : .................. cm
5. Eliminasi
Miksi : ...................................................................................
Defekasi :
...................................................................................
6. Pemeriksaan Penunjang
a. Pemeriksaan Laboratorium
Darah, tanggal:
Hemoglobin :
.................. gr% (Normal:
......... - ............)
Hematokrit :
.................. (Normal: ......... - ............)
Golongan darah :
..................
Bilirubin :
.................. (Normal:
......... - ............)
GDS :
.................. (Normal:
......... - ............)
b. Pemeriksaan penunjang lain:
.......................... Tanggal ..........................
Hasil:
....................................................................................................................................................................................................................................
c. Catatan Medik lain
..................................................................................................................
..................................................................................................................
II.
INTERPRETASI
DATA
A. Diagnosa kebidanan
..............................................................................................................................................................................................................................................................
Data Dasar:
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
B. Masalah
..............................................................................................................................................................................................................................................................
Data Dasar:
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
C. Kebutuhan
..............................................................................................................................................................................................................................................................
Data Dasar:
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
III.
IDENTIFIKASI
DIAGNOSA/MASALAH POTENSIAL DAN ANTISIPASI PENANGANAN
A. Diagnosa Potensial
..............................................................................................................................................................................................................................................................
Data Dasar:
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
B. Masalah Potensial
..............................................................................................................................................................................................................................................................
Data Dasar:
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
C. Antisipasi
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
IV.
MENETAPKAN
KEBUTUHAN TERHADAP TINDAKAN SEGERA BERDASARKAN KONDISI KLIEN
A. Mandiri
..............................................................................................................................................................................................................................................................
B. Kolaborasi
..............................................................................................................................................................................................................................................................
C. Merujuk
..............................................................................................................................................................................................................................................................
V.
RENCANA
ASUHAN YANG MENYELURUH, tanggal ............................jam .......
VI.
IMPLEMENTASI
Tanggal
............................... jam ..........
VII. EVALUASI
Tanggal
............................... jam ..........
