ASUHAN KEBIDANAN PADA BAYI BARU LAHIR

I.

PENGKAJIAN

1.1

Data Subyektif

Tanggal Pengkajian

:..........................................

Pukul

:..........................................

Tempat

:..........................................

Nomor Rekam Medik :.........................................

1.1.1 Identitas Klien
Nama Anak

...........................

Nama Ibu

: .........................

Umur

...........................

Umur

: .........................

Suku/ Kebangsaan

...........................

Suku/

: .........................

Kebangsaan
Agama

...........................

Agama

: .........................

Pendidikan

...........................

Pendidikan

: .........................

Pekerjaan

............................

Pekerjaan

: .........................

Penghasilan

............................

Penghasilan

: .........................

Alamat

............................

Alamat

: .........................

1.1.2 Keluhan Utama :

............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
...........
1.1.3 Riwayat Antenatal
G.............P...........I..........A........H.........umur kehamilan ...................minggu
Riwayat ANC : teratur/ tidak, ..............kali, di ...............................oleh ......................
Imunisasi TT : ..................................TT 2 tanggal ..........................
TT 3 tanggal ....................................TT 4 tanggal : .......................
TT 5 tanggal : .......................................
Kenaikan BB : ..................kg
Keluhan saat hamil : ......................

Penyakit saat hamil : .......................................

Kebiasaan makanan : ..........................................
Obat / jamu : .............................................................
Merokok : ..................................................
Komplikasi Ibu : .......................................
Janin : ..............................................
1.1.4 Riwayat persalinan
Lahir tanggal

: ........................................jam : .................

Tempat persalinan

: ........................................

Penolong

: ........................................

Jenis Persalinan

: spontan / tindakan, atas indikasi : ........................................

Lama Persalinan : Kala I : ..................jam......................menit.

Kala II : .................jam .....................menit.
Komplikasi

a.

Ibu : Hipertensi/ hipotensi, partus lama, penggunaan obat, perdarahan, KPD, infeksi.

b.

Janin : Prematur/ post matur, malposisi/mal presentasi. Gawat janin. Ketuban campur
mekonium,prolaps tali pusat.

1.1.5 Keadaan Bayi Baru Lahir

BB/ PB : .......................gram/ .......................cm.
Caput Sucedanium : ...........................
Cepal Hematoma : ...........................
Resusitasi : Rangsangan : ya/ tidak
Penghisapan lendir : ya / tidak.
Ambu bag : ya / tidak.
O2 : ya / tidak
Cacat bawaan : .........................................................
1.2 Data Obyektif
1.2.1

Pemeriksaan Umum

a.

Kesadaran : ................

b.

Suhu : .........................C : axial/ oral/ rektal.

c.

Nadi : ..........................x/menit : teratur/ tidak teratur ; dalam/dagkal

d.

BB :....................kg.

e.

TB : ..........cm

f.

Tali pusat : ......................

1.2.2

Pemeriksaan khusus

a.

Inspeksi
Kepala

: .................................................................................................................

Muka

: .................................................................................................................

Mata

: .................................................................................................................

Mulut

: .................................................................................................................

Hidung

: .................................................................................................................

Telinga

: .................................................................................................................

Leher

: .................................................................................................................

Legan tangan

: .....................................................................................................

Dada

: .................................................................................................................

Perut

: .................................................................................................................

Genetalia

: .................................................................................................................

Tungkai dan kaki

Anus
Punggung
Kulit
b.

: .....................................................................................................

: .................................................................................................................
: .................................................................................................................
: .................................................................................................................

Reflek :
Moro

: .................................................................................................................

Rotting

: .................................................................................................................

Swallowing : .................................................................................................................
Graphs

: .................................................................................................................

Sucking

: .................................................................................................................

Tonicneck : .................................................................................................................
c.

Antropometri :
PB

: ....................cm

LK

: ....................cm

LD

: ....................cm

LILA
d.

1.2.3

: ....................cm

Eliminasi
Miksi

:..........................

Mekonium

: .........................

Pemeriksaan penunjang/ laboratorium

............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
.......................................................

II.

IDENTIFIKASI DIAGNOSA/ MASALAH AKTUAL

No

III.

Tanggal/

Data

Data

Diagnosa/ masalah

Pukul

subyektif

Obyektif

aktual

ANTISIPASI DIAGNOSA/ MASALAH POTENSIAL

No

Tanggal/

Data

Data

Diagnosa/ masalah

Pukul

subyektif

Obyektif

aktual

IV.

IDENTIFIKASI KEBUTUHAN SEGERA

Tanggal :...................................

Pukul :

..........................................
No

V.

Diagnosa

Tindakan/ kebutuhan segera

INTERVENSI/ RENCANA ASUHAN

Tanggal : ................................

Pukul :

........................................
No

VI.

Diagnosa

Intervensi

Rasional

IMPLEMENTASI/ PELAKSANAAN
Tanggal : ...............................

Pukul :

...........................................

1.
..........................................................................................................................................
2.
..........................................................................................................................................
3.
..........................................................................................................................................

4.
..........................................................................................................................................
5.
..........................................................................................................................................
6.

Dst............

VII.

EVALUASI
Tanggal : ...............................

Pukul :

.........................................

................................................................................................................................
O

................................................................................................................................
A

................................................................................................................................
P

................................................................................................................................

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