KEMENTERIAN KESEHATAN RI

BADAN PENGEMBANGAN DAN PEMBERDAYAAN SDM KESEHATAN

POLITEKNIK KESEHATAN MATARAM
Jalan Prabu Rangkasari Dasan Cermen Cakranegara-Mataram
Telepon (0370) 631160-621383 Faximile (0370) 621383
Website: www.poltekkesmataram.ac.id, Email:admin@poltekkesmataram.ac.id

ASUHAN KEBIDANAN PADA BAYI NY “..........” USIA ……

PATOLOGIS DENGAN ……………............
DI .......................................................
TANGGAL ................................

Tanggal masuk :_______________________

Pukul :_______________________
No. RM :_______________________
Tempat :_______________________

I. PENGUMPULAN DATA DASAR TGL/JAM :______________________

A. Data Subyektif (S)
1. IdentitasBayi
Nama : ...........................................................................
Umur : ...........................................................................
Tanggallahir : ...........................................................................
2. Identitas Orang Tua/Wali
NamaKlien : NamaSuami :
Umur : Umur :
SukuBangsa : SukuBangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamatlengkap :
A. Anamnesa
3. Keluhanutama :

Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Mataram 2015/2016

Nama:Nim :Ulfa Nadia Nurul F/P07 124 115 045
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4. RiwayatPerjalananPenyakit :
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5. RiwayatKehamilan
Hamil :.................................................................
Frekuensi ANC :.................................................................
Imunisasi TT :.................................................................
Kenaikan BB Hamil :.................................................................
KejadianwaktuHamil :.................................................................

Riwayatpenyakit/kehamilan
a. Perdarahan : ...................................................
.........
b. Eklamsia : ...................................................
.........
c. Pre eklamsi
: ............................................................
d. PenyakitKelamin : ...................................................
.........
e. Penyakit Lain : ............................................................

Kebiasaanwaktuhamil
a. Makanan : ......................................................................
b. Obat-obatan/jamu : ......................................................................
c. Merokok : ......................................................................
d. Lain-lain : ......................................................................
6. RiwayatPersalinan
Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Mataram 2015/2016
Nama:Nim :Ulfa Nadia Nurul F/P07 124 115 045
 a. Lama kala I
: ......................................................................
b. Lama Kala II
: ......................................................................
c. Warna air ketuban
: ......................................................................
d. Jenispersalinan : .......................................
...............................
e. KomplikasiPersalinan : ...................................................
...................
f. Penolong : .......................................
...............................
g. Jam/tgl/lahir : ...................................................
...................
h. Jeniskelamin : ...................................................
...................
i. BB/PB : ...................................................
...................
j. Pemberianobat : .......................................
...............................
k. IMD : ...................................................
...................

7. Status Imunisasi
Hepatitis B
Tanggal :

8. PolaKebutuhanSehari-Hari
a. Nutrisi
Pemberian ASI :
Lama :
Lain-lain :
b. Eliminasi
- BAK
Frekuensi:
Warna :
Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Mataram 2015/2016
Nama:Nim :Ulfa Nadia Nurul F/P07 124 115 045
 - BAB
Frekuensi:
Warna :
Konsistensi :

B. Data Obyektif
1. PemeriksaanUmum
KeadaanUmum
: ........................................................................................
Kesadaran : ..........................................................................
..............
BB : ........................................................................................
Tanda – tanda vital :
DenyutJantung : ......... x/menit
Nadi : ......... x/menit
Respirasi : ......... x/menit
Suhu : ..........C
2. PertumbuhandanAntropometri
BeratBadanLahir :......... kg
BB sekarang :......... kg
Lingkarkepala :......... cm
Lingkar dada :......... cm
Lingkarlengan :......... cm
3. PemeriksaanFisik
a. Ubun- ubun : caput suksedenum ( ), chepal hematoma ( ),
UUB datar ( ),
molase( ), pembengkakan ( ), daerah yang cekungpada
kepala ( ), ukuranlingkarkepala normal ( ), kelainan ( )
b. Muka: simetris ( ), kelainan ( )
c. Mata : bersih ( ), skleraikterus ( ), infeksi ( ), Strabismus ( ),
konjungtiva ( ), trauma edema palpebra ( )
d. Telinga : lunak ( ), kelainan ( ), letaksejajardengankontusmata ( ),
infeksi ( )
e. Hidung : lunak ( ), pernapasancupinghidung ( ), sekret ( )
f. Mulut: warnabibir ( ), labioskisis ( ), sianosis ( ), palatum
lunak ( ), palatoskisis ( ), labiogenatopalatoskisis ( ),
Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Mataram 2015/2016
Nama:Nim :Ulfa Nadia Nurul F/P07 124 115 045
 hipersalivasi ( ),
g. Leher : pembengkakankelenjartiroid ( ), tumor/massa ( ),
bendunganvena jugularis ( ), dapatdigerakkankekiridan
kekanan ( ), sindrom down ( )
h. Abdomen : simetris ( ), perdarahantalipusat ( ), jumlahpembuluh
darah ( ), hernia umbilikalis ( ), hernia diafragmatika ( ),
kelainan : omfalokel( ), gastroskisis ( ), hepatosplenomegali
( )
i. Punggung : pembengkakan (spina bifida danokulta) ( )
j. Genitalia : jeniskelamin( ), ......................................................................
......................................................................
k. Anus : berlubang ( ), pengeluaranmekonium ( )
l. Ekstremitas
Atas : gerakan normal ( ), jumlahjari normal ( ), trauma lahir ( ),
sianosispada kuku ( )
Bawah : gerakan normal ( ), simetris ( ), jari kaki normal ( ),
sianosispada kuku ( )
m. Kulit : verniks ( ), warnakulit ( ), pembengkakkan ( ),
tanda lahir ( )
3. Reflek :
Reflek Moro : ada/ tidak
Reflek Rooting : ada/ tidak
Reflek Sucking : ada/ tidak
Reflek Swallowing : ada/ tidak
Reflek Grasping : ada/ tidak
ReflekTonik neck : ada/ tidak
ReflekGalants : ada/ tidak
Reflek Walking : ada/ tidak
4. POLA ELIMINASI
Miksi :
Defekasi/pengeluaran mekonium :
5. APGAR SCORE
No Aspek yang 1 menit Nilai 5 menit Nilai
dinilai pertama kedua
1 Appearance
2 Pulserate
3 Grimace
Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Mataram 2015/2016
Nama:Nim :Ulfa Nadia Nurul F/P07 124 115 045
 4 Activity
5 Respiratory

6. Pemeriksaanpenunjang (jikadilakukan)
a. Darah : tgl..................................
HGB : ...............................
RBC : ...............................
WBC : ...............................
PLT : ...............................
GDS : ...............................
Al : ...............................
HMT : ...............................
Golongandarah : .....................

II. INTERPRETASI DASAR

1. Diagnosa kebidanan :
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2. Masalah :
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3. Kebutuhan :
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III. MENGINDENTIFIKASI DIAGNOSA/ MASALAH POTENSIAL

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Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Mataram 2015/2016

Nama:Nim :Ulfa Nadia Nurul F/P07 124 115 045
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IV. KEBUTUHAN TERHADAP TINDAKAN SEGERA

Mandiri......................................................................................................................
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Kolaborasi................................................................................................................
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..
Rujukan....................................................................................................................
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V. RENCANA ASUHAN YANG MENYELURUH

Tanggal : pukul :
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VI. PELAKSANAAN ASUHAN

Tanggal : pukul :
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Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Mataram 2015/2016
Nama:Nim :Ulfa Nadia Nurul F/P07 124 115 045
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VII. EVALUASI
Tanggal : pukul :
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Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Mataram 2015/2016

Nama:Nim :Ulfa Nadia Nurul F/P07 124 115 045
 Mengetahui,

Mahasiswa Pelaksana

( )

Pembimbing Lahan Pembimbing Pendidikan

( ) ( )

Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Mataram 2015/2016

Nama:Nim :Ulfa Nadia Nurul F/P07 124 115 045