FORMAT PENGKAJIAN ASUHAN KEBIDNAN BAYI BARU LAHIR

Tanggal masuk : .................................. Tanggal pengkajian : ................................

Jam masuk : ................................. Jam masuk : .................................
Tempat : ................................. Pengkaji : .................................

I. PENGKAJIAN DATA
A. BIODATA
1. Identitas pasien
Nama : .................................................
Umur : .................................................
Tgl/Jam lahir : .................................................
Jenis kelamin : .................................................
BB lahir : .................................................
Panjang badan : .................................................
2. Identitas Ibu Identitas Ayah
Nama Ibu : ............................ Nama Ayah : ............................
Umur : ............................ Umur : ............................
Agama : ............................ Agama : ............................
Suku/bangsa : ............................ Suku/bangsa : ............................
Pendidikan : ............................ Pendidikan : ............................
Pekerjaan : ............................ Pekerjaan : ............................
Alamat : ............................ Alamat : ............................

B. ANAMNESA
DATA SUBJEKTIF
1. Riwayat kesehatan ibu
Jantung : ............................
Hipertensi : ............................
DM : ............................
Malaria : ............................
Ginjal : ............................
Asma : ............................
Hepatitisa : ............................
Riwayat Operasi abdomend/ SC : ............................
2. Riwayat penyakit keluarga
Hipertensi : ............................
DM : ............................
Asma : ............................
Lain – lain : ............................
3. Riwayat persalinan sekarang
G........P.........A.........UK........minggu
Tanggal/Jam persalinan : ............................
Tempat persalinan : ............................
Penolong persalinan : ............................
Jenis persalinan : ............................
Komplikasi persalinan : ............................
- Ibu : ............................
- Bayi : ............................
Ketuban Pecah : ............................
 Keadaan plasenta
Tali pusat
Lama persalinan
Jumblah perdarahan
4. Riwayat kehamilan
a. Riwayat komplikasi kehamilan
Perdarahan
Preeklamsi/eklamsi
Penyakit kelamin
Lain-lain
b. Kebiasaan ibu saat hamil
Makan
Obat-obatan
Jamu
Merokok
: ............................
: ............................
: kala I :.................., kala II..................
kala III :................ kala IV.................
: kala I :.................., kala II..................
kala III :................ kala IV.................
: ............................
: ............................
: ............................
: ............................
: ............................
: ............................
: ............................
: ............................

C. DATA OBJEKTIF
Antropometri
1. Berat bada n : ............................
2. Panjang badan : ............................
3. Lingkar kepala : ............................
4. Lingkar dada : ............................
5. Lingkar perut : ............................
Pemeriksaan umum
1. Jenis kelamin : ............................
2. APGAR score : ............................
3. K/U bayi : ............................
4. Suhu : ............................
5. Bunyi Jantung : ............................
6. Frekuensi : ............................
7. Respirasi : ............................
Pemeriksaan fisik
1. Kepala 2. Mata :
Fontanel anterior : ....................... Letak : ....................
Sutura sagitalis : ............................ Bentuk : ....................
Caput succedabneum: .................... Sekret : ....................
Cepal hematomma : .................... Conjungtiva : ....................
Sclera : ....................
3. Hidung 4. Mulut
Bentuk : .................... Bibir : ....................
Sekret : .................... Palatum : ....................
5. Telinga 6. Leher
Bentuk : .................... Pergerakkan : ....................
Simestris : .................... Pembengkkan : ....................
Secret : .................... Kekakuan : ....................
7. Dada 8. Paru – paru
Bentuk : .................... Suara napas : ....................
Retraksi dinding dada : .................... Resfirasi : ....................
 9. Abdomen 10. Pungggung
Kembung : .................... Ada/tidak ada tulang belakang
Tali pusat : ....................
11 Tangan dan kaki
Gerakan : ....................
Bentuk : ....................
Jumblah : ....................
Warna : ....................
Reflek
- Reflek morro : ..................................................
- Reflek rooting : ..................................................
- Reflek walking : ..................................................
- Reflek babynskin : .................................................
- Reflek graping : .................................................
- Reflek sucking : .................................................
- Reflek tonic neck : .................................................

D. PEMERISAAN PENUNJANG
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II. IDENTIFIKASI DIAGNOSA, MASALAH DAN KEBUTUHAN
Diagnosa : By. Ny.
S :-
-
O : - Keadaan umum :
- Kesadaran : CM
- Observasi vital sign
Frekuensi jantung : ........x/menit, S: .....℃, RR: .....x/menit
- Antropometri
BB :
PB :
LK/LD/LP :
- A/S : ...../......
- Masalah : Tidak ada
Kebutuhan
- ........................................................
- .......................................................
- .......................................................
- .......................................................

III. ANTISIPASI DIAGNOSA MASALAH POTENSIAL

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IV. ANTISIPASI TINDAKAN SEGERA

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V. INTERVENSI

No Intervensi Rasional

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VI. IMPLEMENTASI
No Jam Implementasi Paraf
1

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 VII. EVALUASI

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Hari ke : II
Tanggal :

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