RESUME ASUHAN KEPERAWATAN MATERNITAS (BBL)

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PENGKAJIAN
I. ANAMNESA
1. BIODATA
Nama : ............................................................
Umur : ............................................................
Pekerjaan : ............................................................
Status : ............................................................
Agama : ............................................................
Alamat : ............................................................
Nama ibu : ............................................................
Pekerjaan : ............................................................
Alamat : ............................................................
Diagnosa medis : ............................................................

2. KELUHAN UTAMA
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3. RIWAYAT KESEHATAN
a. Riwayat Penyakit Saat Ini
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b. Riwayat Kesehatan Masa Lalu
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c. Riwayat Kesehatan Keluarga
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DATA FOKUS

Lahir jam :......................................... Laki- laki/ perempuan ........... Hidup/ Mati

Panjang badan : ....................... BBL ..................... LK ................... LD..........................

APGAR Score : ..............................................................................................................

Tanda- tanda Vital : Nadi ............................ Suhu ........................ RR ............................

Caput succendaneum : ..............................................................................................................

Cephal hematom : ..............................................................................................................

Anus : ada / tidak

Kelainan/ lain- lain : ...........................................................................................................

keadaan umum
berat BAK/ Lain-
Tgl/ jam (TTV, refleks Minum
badan BAB lain
primitif)
 EVALUASI
NO S O A P I E
DX