Varney BBL Patologi

ASUHAN KEBIDANAN PATOLOGI PADA BAYI NY “J”
DENGAN BBLR UMUR HARI PERTAMA DI

RUANG NICU RSUD KOTA MATARAM
TANGGAL 25-29 JUNI 2016
Tanggal pengkajian : 25 Juni 2016

Pukul : 23.01 WITA
Tempat : Ruang NICU-RSUD Kota Mataram
I. PENGKAJIAN DATA
A. DATA SUBYEKTIF
B. Identitas
1. Identitas Bayi
Nama :
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Umur :
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Tanggal lahir :
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2. Identitas Orang Tua/Wali
Nama
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Umur
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Agama
:............................................................................
Pendidikan
:............................................................................
Pekerjaan
:............................................................................
Suku/bangsa
:............................................................................
Asuhan Kebidanan Bayi Baru Lahir Patologi DIV Kebidanan Poltekkes Kemenkes
Mataram
Alamat
:............................................................................
C. Keluhan utama pada bayi
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D. Riwayat Kehamilan
Riwayat obstetrik (ibu) :G P A H
Keluhan yang dialami ibu : TM1:
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TM2:
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TM3 :
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HPHT : ....................................................
HTP : ....................................................
Usia Kehamilan : ....................................................
Kejadian selama hamil :
a. Riwayat penyakit/kehamilan
Perdarahan : ada/tidak
Preeklampsia : ada/tidak
Eklampsia : ada/tidak
Penyakit/kelainan : ada/tidak
b. Kebiasaan waktu hamil
Makan : .................................................................
Obat-obat/jamu : .................................................................
Merokok : .................................................................
Lain-lain : .................................................................
c. Komplikasi
Ibu : .................................................................
Bayi : .................................................................
E. Riwayat Persalinan
a. Ketuban
Mataram
Pecah jam : ............................
Warna : ............................
Jumlah : ............................
b. Riwayat Persalinan Sebelumnya
Lama kala I : ......................................................................
Lama Kala II : ......................................................................
Warna air ketuban: ......................................................................
Jenis persalinan : ......................................................................
Penolong : ......................................................................
Jam/tgl/lahir : ......................................................................
Jenis kelamin : ......................................................................
BB/PB : ......................................................................
F. Riwayat Persalinan Sekarang
Jenis Persalinan : ......................................................................
Ditolong oleh : ......................................................................
Jam/tangal lahir : ......................................................................
Jenis kelamin : ......................................................................
Berat badan : ......................................................................
Panjang badan : ......................................................................
DATA OBYEKTIF
1. APGAR Score
No Aspek yang 1 menit 5 menit 10 menit
dinilai
1 Denyut jantung
2 Usaha nafas
3 Tonus otot
4 Reflek
5 Warna kulit
Jumlah
2. Pemeriksaan Umum
KU : ........................................................................................
Mataram
Kesadaran : ........................................................................................
BB : ........................................................................................
Tanda – tanda vital :
Nadi : ...........x/menit
Respirasi : ..........x/menit
Suhu : ..........C
3. Pemeriksaan Antropometri
BB :
PB :
Lika :
Lida :
Lila :
4. Pemeriksaan Fisik
Kepala :
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Muka :
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Mata :
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Hidung :
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Telinga :
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Mulut :
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Leher :
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Dada :
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Ketiak :
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Mataram
Abdomen :
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Genetalia :
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Ekstremitas :
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Anus :
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5. Pemeriksaan penunjang (jika dilakukan)
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II. INTERPRETASI DATA

Diagnosa
: .....................................................................................................................
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Data Dasar :
a. Data Subyektif
Mataram
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b. Data Obyektif
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III. DIAGNOSA POTENSIAL / MASALAH POTENSIAL

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Mataram
IV. KEBUTUHAN TERHADAP TINDAKAN SEGERA
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V. PERENCANAAN
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VI. PELAKSANAAN
Mataram
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VII. EVALUASI
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Mataram
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Mengetahui,
Mahasiswa Pelaksana
( )
Mataram
Pembimbing Lahan Pembimbing
Pendidikan
( ) (
)
Mataram

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ASUHAN KEBIDANAN PATOLOGI PADA BAYI NY “J”

DENGAN BBLR UMUR HARI PERTAMA DI

Tanggal pengkajian : 25 Juni 2016

5. Pemeriksaan penunjang (jika dilakukan)

II. INTERPRETASI DATA

III. DIAGNOSA POTENSIAL / MASALAH POTENSIAL

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