KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN KEMENKES MALANG

JURUSAN KEBIDANAN
PROGRAM STUDI KEBIDANAN KEDIRI
Jl. KH Wachid Hasyim 64 B Kediri

FORMULIR ASUHAN KEBIDANAN UNTUK BAYI

Tanggal / Jam MRS : …………………………………………………………………
Tanggal / Jam pengkajian : ..……………………………………………………………….
No. Reg :....................................................................................................
Ruangan :....................................................................................................
Dx Medis :.....................................................................................................

A. DATA SUBYEKTIF
BIODATA
Identitas Bayi
Nama : ………………………………………….……………………..
Tanggal lahir : ………………………………………………………………...
Usia saat ini : ………………………………………………………………...
Jenis Kelamin : ………………………………………………….......................
Anak ke : ………………… dari ………………..saudara

Identitas Orang tua

Nama Ibu : …………………………………………………………………
Umur : …………………………………………………………………
Suku Bangsa : …………………………………………………………………
Agama : ………………………………………...……………………….
Pendidikan : …………………………………………………………………
Pekerjaan : …………………………………………………………………
Penghasilan : …………………………………………………………………
Alamat Rumah : …………………………………………………………………

Nama Ayah : ....………………………………………………………………

Umur : …………………………………………………………………
Suku Bangsa : …………………………………………………………………
Agama : ………………………………………...……………………….
Pendidikan : …………………………………………………………………
Pekerjaan : …………………………………………………………………
Penghasilan : …………………………………………………………………
Alamat Rumah : …………………………………………………………………

ANAMNESA
Sumber Informasi :

1. Keluhan Utama:
………………………………………………………………………………….
………………………………………………………………………………….
………………

2. Riwayat Penyakit sekarang:

………………………………………………………………………………….
………………………………………………………………………………….
……………………………………………………………………………………………
…………….
 3. Riwayat Kesehatan Ibu Saat Hamil
a. Riwayat penyakit : ……………….………………………………………………..
b. Kebiasaan merokok: ……………………………….……………….……………..
c. Kebiasaan minum obat: …………………….……………………………………..

4. Riwayat Natal
a. Proses Kelahiran : ……………………………….……………….……………….
b. Berat lahir: ………….gram Panjang lahir: ………………….. cm
c. Tindakan Resusitasi : ……………………………….……………….…………….

d. Ketuban : Pecah …….Jam sebelum persalinan, warna:…………………......

Dipecah saat persalinan, warna : ………………………………….
e. Plasenta : ……………………………...………………………………………….
f. IMD : ……………………………...………………………………………….
g. Vitamin K1 : …………………………...………………………………………….
h. Kelainan yang ditemukan : …………………………………………………….…..

5. Riwayat pemberian ASI: …………………………………………….…………………

……………………………………………………………………………………………
………………………………………………………………………………………

6. Riwayat Imunisasi yang sudah diberikan

Jenis Imunisasi Tanggal Pemberian

B. DATA OBYEKTIF
Pemeriksaan Fisik
1. Keadaan Umum :
2. Kesadaran :
3. Tanda-tanda vital
Suhu : suhu axilar.....0 C
Nadi : ....................... x/menit
Pernafasan : ....................... x/menit
4. Pengukuran antropometri
Berat badan : .......................gram
Panjang badan : .......................cm
Status gizi :………………………………
5. Kepala
a. Lingkar kepala: …………. Cm
b. Rambut :
c. Mata :
d. Wajah :
e. Telinga :
f. Hidung :
g. Mulut :
6. Leher :
7. Thorak
Gerak nafas :
Bentuk :
Irama nafas :
 Bunyi nafas :
Jantung :

8. Abdomen
Inspeksi : Bentuk :
Acites :
Tali pusat :
Palpasi : Massa :
Fecalit :
Distensi :
Pembesaran Hepar :
Perkusi :
Auskultasi : Peristaltik usus............x/menit

9. Genetalia
Labia :
Scrotum :

10. Anus :

11. Ekstremitas
Atas :
Bawah :

12. Neurologi
Kaku Kuduk :
Muntah :
Kejang :
Panas :

13. Refleks Bayi

a. Rooting reflek :
b. Sucking reflek :
c. Moro reflek :
d. Babinski reflek :
e. Grasp reflek :
f. Swallowwing reflek :

14. Perkembangan (lampirkan KPSP sesuai usia bayi);

a. Motorik kasar:
………………………………………………………………………………………
…………………………………………………………………………….
b. Motorik halus:
………………………………………………………………………………………
……………………………………………………………………………
c. Bicara/bahasa;
………………………………………………………………………………………
……………………………………………………………………………
d. Sosial kemandirian:
………………………………………………………………………………………
…………………………………………………………………………

15. Pemeriksaan penunjang

 a. Laboratorium:
………………………………………………………………………………………
…………………………………………………………………………………
b. Foto:
………………………………………………………………………………………
………………………………………………………………………………….......
c. Lain-lain :
………………………………………………………………………………………
…………………………………………………………………………………........

C. ANALISIS:
………………………………………………………......................................................
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D. PENATALAKSANAAN :
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Kediri, ……………………..

Pembimbing Klinik, Mahasiswa,

………………………………. ….………………………….
NIP. NIM.

Dosen Pembimbing

….……………………………..
NIP.
 CATATAN PERKEMBANGAN

Nama :…………………………………………………………………………………
Umur :………………………………………………………………………………….
No. Reg :………………………………………………………………………………….

Tgl SUBYEKTIF OBYEKTIF ANALISIS PENATALAKSANAAN TTD