ASUHAN KEBIDANAN BAYI BARU LAHIR

Tanggal pengkajian:........... Jam: ........... No. Rekam Medik:...........

I. IDENTITAS
1.........................Identitas Bayi
Nama : .....................................................
Jenis Kelamin : .....................................................
Tanggal MRS : .....................................................
Umur/ Tanggal Lahir : .................................................... ( hari, jam, menit)
Anak Ke : .....................................................
2....................Identitas Orang Tua
Nama Ayah : ........................... Nama Ibu : ..................................
Umur : ........................... Umur : ..................................
Agama : ........................... Agama : ..................................
Suku/ Bangsa : ........................... Suku/ Bangsa : ..................................
Pendidikan : ........................... Pendidikan : ..................................
Alamat : ........................... Alamat : ..................................

II. KELUHAN UTAMA

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III. RIWAYAT ANTENATAL

Penyakit/ Kesehatan Ibu dan pengobatan
Sebelum hamil : ...................................................................................
Selama hamil (trimester I-III) : ...................................................................................

IV. RIWAYAT PROSES PERSALINAN

1. Umur Kehamilan......................................................:

2. Kehamilan tunggal/ kembar......................................:

3. Lama persalinan kala I..............................................:

Kelainan : .............................................................................
4. Lama persalinan kala II............................................:
Kelainan : .............................................................................
5. Air Ketuban..............................................................:

Ketuban pecah : .................................................jam sebelum lahir

Jumlah : ........................................................................ cc
Warna : Jernih Keruh Mekonium
Bau : Anyir Lain-Lain Jelaskan .....................
Letak bayi : .............................................................................
6. Jenis persalinan :................. Spontan
Secsio Caesaria
Vacum Ekstraksi Forceps Ekstraksi
7. Indikasi.....................................................................:

8. Obat yang diberikan.................................................:

Selama persalian : .............................................................................

 9. Tanda gawat janin.....................................................:

Sebelum lahir : .............................................................................

10. Berat badan lahir......................................................:

11. Panjangbadan lahir...................................................:

12. Lingkar dada.............................................................:

13. Lingkar kepala..........................................................:

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

15. Menetek pertama kali...............................................:

16. Resusitasi.................................................................:

17. Obat-obatan yang diberikan......................................:

18. Imunisasi..................................................................:

V. RIWAYAT KESEHATAN SAAT INI

1. Keadaan umum.........................................................:

2. Diagnosis medis.......................................................:

3. Tindakan medis........................................................:

VI. PEMERIKSAAN BAYI

1. Tanda vital
Suhu : ......................... ◦C
Nadi : ......................... kali/menit
Pernapasan : ......................... kali/menit
2. Pernafasan
Teratur Ronkhi Apnea Tidak teratur
Vesikuler Wheezing Cuping Hidung
Lain-lain, jelaskan .......................................................................................................
3. Peredaran darah
Denyut nadi : Teratur Tidak Teratur
Lemah Kecil

Ekstremitas atas dan bawah : Hangat Dingin

Lemah Pucat
Biru Merah Muda
4. Eliminasi
Buang air kecil : Ya Belum
Mekonium : Ya Belum
Feses : Ya Belum
Konsistensi : ................................ Warna : .....................................
Frekuensi : ................................ Lain-lain : .....................................
5. Refleks
Menghisap Menelan Rooting
Babinski Menggenggam Moro
 Tonic neck
6. Pemeriksaan fisik
a.Kepala
Simetris Asimetris Chepal Hematoma
Microchepal Macrochepal Caput Succedanum
Hidrosefalus Luka Lecet Edema
Mongoloid Lain-lain, jelaskan ...................................................
b. Dada
Simetris Asimetris Ginekomasti
Lain-lain, jelaskan .........................................................................................
c.Ekstremitas
Tangan : Normal Kelainan, Jelaskan ..............
Kaki : Normal Kelainan, Jelaskan ..............
d. Abdomen
Supel Distended Meteorismus
Flat Lain-Lain, jelaskan ...................................................
Bising usus : Positif Negatif
Meningkat Menurun
Tali Pusat : Perdarahan : Ya Tidak
Bau : Ya Tidak
Lain-lain, jelaskan ................................................................................................
e. Alat kelamin :............................... Normal
Kelainan, Jelaskan
f. Anus : Normal......... Atresia Ani
Kelainan, jelaskan ....................................................
g. Kulit
Kemerahan Biru Pucat
Kuning Edema Mengelupas
Kering Transparan
Lain-lain, jelaskan .....................
Turgor : baik Menurun Jelek
h. Tonus otot
Baik Kurang Buruk
i. Lain-lain
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7. Pemeriksaan penunjang
a. Laboratorium................................................................................:

b. Radiologi......................................................................................:

VII. ASSESMENT
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VIII. PERENCANAAN (Rencana Asuhan, Implementasi dan Evaluasi)

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