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POLTEKES KEMENKES RI BANDUNG

PROGRAM STUDI KEBIDANAN KARAWANG

JL. KERTABUMI NO.74

FORMAT PENGKAJIAN IMUNISASI

No Register : …………………… Tanggal/ Waktu Pengkajian :……………………

Nama Pengkaji :…………………… Tempat Pengkajian :………....................

I. PENGKAJIAN DATA SUBJEKTIF (S)

A. Biodata Bayi
Nama : ……………….
Tanggal Lahir : ……………….
Umur : ……………….
Jenis Kelamin : ……………….
Anak Ke : ……………….

B. Identitas Orang Tua


Nama Ibu : ………………… Nama Ayah : …………………..
Umur : ………………… Umur : …………………..
Pendidikan : ………………… Pendidikan : …………………..
Pekerjaan : ………………… Pekerjaan : …………………..
Agama : ………………… Agama : …………………..
Alamat : ………………… Alamat : …………………...

C. AlasanKunjungan:………………………………………………………………………
…..…………………………………………………………………………………........
D. Riwayat Kesehatan
a. Riwayat Kesehatan Sekarang
…………………………………………………………………………………
………………………………………………………………………………....

b. Riwayat Kesehatan yang Lalu


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E. Riwayat Kesehatan Keluarga

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F. Riwayat kehamilan, persalinan. dan nifas yang lalu

No. Tahun Usia Persalinan Bayi Nifas


Kehamilan

Jenis Penolong Tempat BB/PP L/P Keadaan Laktasi

G. Riwayat Imunisasi

Jenis Tingkat
Imunisasi Pemberian
I II III IV
HB-0
BCG
Polio
DPT-HB-HIB

H. Pola Aktivitas Sehari-hari


a. Pola Nutrisi :

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b. Pola istirahat

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c. Pola Eliminasi

BAB :............................................

BAK:.............................................

d. Pola Personal Hygiene

Mandi : ............................................

Ganti baju : ............................................

e. Pola Aktifitas

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II. PENGKAJIAN DATA OBYEKTIF

Pemeriksaan Umum Tanda-tanda Vital

1. Kesadaran Umum : ................................ 1. Suhu : ...........


2. Kesadaran : ................................ 2. Nadi : ...........
3. Berat Badan :........... TB :......... LK:........ 3. Respirasi : ...........
4. Pemeriksaan Fisik
a. Inspeksi
Kepala :.................................................................................................................

Mata : ................................................................................................................
Muka : ................................................................................................................

Hidung : ................................................................................................................

Mulut : ................................................................................................................

Telinga : ................................................................................................................

Dada : ................................................................................................................

Kulit : ................................................................................................................

Ekstermitas atas : ....................................................................................................

Ekstermitas bawah : ..................................................................................................

III . ASSESMENT (A)

Diagnosa : ...........................................................................................................................

Masalah Potensial : ............................................................................................................

Antisipasi Masalah Potensial : ...........................................................................................

Kebutuhan : ........................................................................................................................

IV . PENATALAKSANAAN ( P )

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