Nama .....................................

POLTEKKES KEMENKES YOGYAKARTA Keterampilan ke.....................

JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================
ASUHAN KEBIDANAN PADA BAYI/BALITA
………………………………………………………………………………………………………………
……………………………………………………………………………………………………………….

NO.REGRESTASI :……………………………………………………………….
MASUK RS TANGGAL, JAM :…………………………………………………………………………
DIRAWAT DIRUANG :………………………………………………………………………..
Biodata :……………………………………………………………………………………………
Nama Bayi :…………………………………………………………………………………………….
Tanggal lahir :……………………………………………………………………………………………
Nama Ibu :………………………….. Ayah………………………………………………..
Umur :…………………………... ……………………………………………………
Agama :…………………………... ……………………………………………………
Suku/Bangsa :…………………………... …………………………………………………….
Pendidikan :…………………………… ……………………………………………………...
Pekerjaan :…………………………… ……………………………………………………..
Alamat :………………………….. ……………………………………………………

DATA SUBJEKTIF
1. Keluhan utama (anak/orang tua)
………………………………………………………………………………………………………
………………………………………………………………………………………………………
2. Riwayat penyakit sekarang
………………………………………………………………………………………………………
………………………………………………………………………………………………………
3. Respon keluarga
………………………………………………………………………………………………………
……………………………………………………………………………………………………....
4. Riwayat kesehatan yang lalu
a. Riwayat intranatal
Masa Kehamilan :…………..minggu
Lahir tanggal…………………………jam………………….
Jenis persalinan : spontan/tindakan……………………………………………………...
Atas indikasi ………………………………………………………….
Penolong :…………………………………………………………………………
Lama persalinan : Kala I…………………..jam…………………..menit
Kala II………………….jam…………………..menit
Komplikasi
 Ibu :Hipertensi/hipotesis, partus lama, penggunaan obat, infeksi/suhu badan
naik , KPD, perdarahan
 Janin : Prematur/postmatur, malposisi/malpresentasi, gawat janin, ketuban
campur mekonium, prolaps tali pusar keadaan bayi baru lahir
BB/BP lahir……………………………………………………………………
Nilai APGAR: 1 menit/ 5 menit/ 10 menit:………./………………..
b. Riwayat pemberian nutrisi
ASI Eksklusif ya/tidak. Lama pemberian ASI……………….bulan/tahun
PASI sejak umur………….bulan/tahun, jenis……………………………………………..
Makanan tambahan sejak umur……………..bulan/tahun,jenis……………………………
Keluhan……………………………………………………………………………………..
5. Status kesehatan terakhir
a. Riwayat alergi
Jenis Makanan:……………………………………………………………………………..
Debu :…………………………………………………………………………………...
Obat :…………………………………………………………………………………..
 POLTEKKES KEMENKES YOGYAKARTA
JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================

b. Imunisasi Dasar :…………………………………………………………………………

Ulang :………………………………………………………………………..
c. Uji skrining :……………………………………………………………………….
d. Riwayat penyakit yang lalu
………………………………………………………………………………………………
………………………………………………………………………………………………
A. Data Objektif
1. Pemeriksaan Umum
a.Keadaan umum :………………………………………………………………………
b.Kesadaran :………………………………………………………………………
c. Tanda vital
Tekanan darah :……………………………………………………………………….
Nadi :……………………………………………………………………….
Pernafasan :……………………………………………………………………….
Suhu :……………………………………………………………………….
d. Status Gizi :TB……………………..cm, BB………………kg
LK…………………….cm,LLA……………...cm

2. Pemeriksaan Fisik
a. Kulit :………………………………………………………………………..
b. Kuku :……………………………………………………………………….
c. Kelenjar getah bening/limfe (palpasi leher atau inguinal)
d. Kepala
Rambut :………………………………………………………………………
Ubun-ubun :………………………………………………………………………
Wajah :………………………………………………………………………
Mata :………………………………………………………………………
Telinga :………………………………………………………………………
Hidung :………………………………………………………………………
Mulut :………………………………………………………………………
Faring dan Laring :…………………………………………………………………..
e. Leher :……………………………………………………………………….
f. Dada :……………………………………………………………………….
Bentuk dan besar :…………………………………………………………………..
Gerakan :……………………………………………………………………….
Payudara :………………………………………………………………………
Paru :……………………………………………………………………….
Jantung :………………………………………………………………………
g. Abdomen
Ukuran dan bentuk :…………………………………………………………………
Gerakan :…………………………………………………………………
Dinding perut :…………………………………………………………………
Auskultasi :…………………………………………………………………
Perkusi :………………………………………………………………….
Palpasi :………………………………………………………………….
h. Anus dan rectum :………………………………………………………………….
i. Genetalia
Laki-laki : (ukuran, bentuk penis, testis, kelainan/perdagangan)
:……………………………………………………………………………
Perempuan : (epispadia, tanda seks sekunder, cairan)
:……………………………………………………………………………
j. Tulang belakang :………………………………………………………………….
 POLTEKKES KEMENKES YOGYAKARTA
JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================
k. Ekstremitas :…………………………………………………………………..
l. Neurologis : ( Kejang, tanda meningeal, kekuatan dan tonus otot)
:………………………………………………………………………

3. Pemeriksaan Penunjang
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
………………………………………………………………………………………………

ANALISA

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

PENATALAKSANAAN
Tanggal…………………………..jam…………………..

................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
 POLTEKKES KEMENKES YOGYAKARTA
JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================