FORMAT PENGKAJIAN ASUHAN KEBIDANAN

PADA BAYI/ BALITA/ANAK PRASEKOLAH

A. PENGKAJIAN
Tanggal :..................................
Waktu :..................................
Tempat :..................................
B. IDENTITAS
a. Identitas Bayi
Nama :..............................
Tgl/Jam lahir :..............................
Jenis kelamin :..............................
b. Identitas Orang tua
Nama ibu : ............................. Nama Suami : .........................
Umur ............................... Umur : .........................
Agama :.............................. Agama : .........................
Pendidikan : ............................. Pendidikan : .........................
Pekerjaan : ............................. Pekerjaan : .........................
Alamat : ............................. Alamat : ..........................

C. DATA SUBYEKTIF
1. Alasan
Datang:......................................................................................................................
...................................................................................................................................
.............
` Keluhan Utama :
...................................................................................................................................
...................................................................................................................................
2. Riwayat Kesehatan:
Dahulu : .........................................................................................................
..........................
Sekarang:
...................................................................................................................................
...................................................................................................................................
 Keluarga:
...................................................................................................................................
3. Riwayat kehamilan, persalinan dan nifas:
Dahulu :
...................................................................................................................................
...................................................................................................................................
Sekarang:
...................................................................................................................................
...................................................................................................................................
4. Riwayat tumbang
Pertumbuhan BB :……...................................……………………...............
Perkembangan anak :..........................................................................................
Kelainan bawaan :..........................................................................................
5. Riwayat Imunisasi :.....................................................................................
6. Pola kebiasaan sehari- hari:
Pola nutrisi :.......................................................................................................
...................................................................................................................................
Pola eliminasi :.......................................................................................................
...................................................................................................................................
Pola istirahat :.......................................................................................................
...................................................................................................................................
Pola aktifitas :.......................................................................................................
...................................................................................................................................
Personal hygiene:....................................................................................................
...................................................................................................................................
7. Pola Sosial Ekonomi :..........................................................................................

D. DATA OBYEKTIF
1. Pemeriksaan Umum
Keadaan umum :.........................................
Kesadaran :..........................................
Vital signs : N =................x/mnt
RR = ..................x/mnt
T = ..................0C
 2. Pengukuran antropometri:
BB :................kg Lingkar kepala/ LK :................cm
PB :................cm LILA :................cm
3. Status Present:
Kepala :...............................
Muka :...............................
Mata :...............................
Hidung :................................
Mulut :.............................
Telinga :...............................
Leher :.............................
Dada :............................
Pulmo/COR :.............................
Abdomen :................................
Genetalia :...............................
Punggung :..............................
Anus :..................................
Ekstremitas :...........................
Kulit :................................

E. ANALISA …...................................................................................................
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F. PENATALAKSANAAN
Tanggal...........................….Jam…...........…
1. ......................................................................................................................................
Hasil : ..........................................................................................................................

2. ......................................................................................................................................
Hasil : ..........................................................................................................................
3. ......................................................................................................................................
Hasil : ..........................................................................................................................

4. ......................................................................................................................................
Hasil : ..........................................................................................................................

5. ......................................................................................................................................
Hasil :...........................................................................................................................

6. ......................................................................................................................................
Hasil :...........................................................................................................................

7. ......................................................................................................................................
Hasil :...........................................................................................................................

8. ......................................................................................................................................
Hasil :...........................................................................................................................

9. ......................................................................................................................................
Hasil :...........................................................................................................................

10. ......................................................................................................................................
Hasil :...........................................................................................................................