FORMAT ASUHAN KERAWATAN BAYI BARU LAHIR

No. Registrasi :.....................................................................................................................

Nama Pengkaji :.....................................................................................................................

Hari/Tanggal :.....................................................................................................................

Waktu Pengkajian :.....................................................................................................................

Tempat Pengkajian :.....................................................................................................................

I. DATA SUBJEKTIF
A. Identitas
Nama Bayi :...............................................................................................................
Hari/Tanggal/Jam Lahir :...........................................................................................
Jenis Kelamin :...........................................................................................................
BB Lahir :..................................................................................................................
PB Lahir :...................................................................................................................
No Identitas :..............................................................................................................

B. Identitas Orang Tua

AYAH IBU

1 2 3

Nama

Usia

Agama

Pendidikan

Suku Bangsa

Pekerjaan

Golongan Darah

Perkawinan

Lama Perkawinan

No.Telepon

Alamat
C. Riwayat Kehamilan
Status GPA : G…….. P……..A……..
Usia Kehamilan :.......................................................................................................
Penggunaan Obat-Obatan
Selama Kehamilan :...................................................................................................
Imunisasi TT :............................................................................................................
Prenatal Care :............................................................................................................
Komplikasi Penyakit Selama Kehamilan :................................................................

D. Riwayat Persalinan Sekarang

Penolong Persalinan :.................................................................................................
Tempat Persalinan :...................................................................................................
Jenis Persalinan :........................................................................................................
Presentasi ;.................................................................................................................
Air Ketuban :.............................................................................................................
Lama Persalianan Kala II :.........................................................................................
Keadaan Tali Pusat....................................................................................................
 Panjang :.......................................................................................................
 Jumlah Vena :...............................................................................................
 JUmlah Arteri :.............................................................................................
 Kelainan :.....................................................................................................

E. Keadaan Bayi Saat Lahir

Nilai APGAR pada 1’ dan 5 :....................................................................................
Resusitasi :.................................................................................................................
Obat – Obatan
 Salep Mata :.................................................................................................
 Vitamin A :...................................................................................................
Pemberian Oksigen :..................................................................................................
Keadaan Umum :
Pernapasan
 Sponta/Tidak :..............................................................................................
 Frekuensi :....................................................................................................
 Teratur/Tidak :.............................................................................................
 Suara Napas :...............................................................................................
 Menangis :....................................................................................................
Suhu :.........................................................................................................................
 Warna Kulit :.............................................................................................................
F. Asupan Cairan
 ASI : ................... Jumlah.........................
 PASI :....................Jumlah..........................
 Infua :....................Jumlah.........................

G. Eleminasi
 BAK : ..................... Warna .........................
 BAB :...................... Warna..........................

H. Istirahat dan Tidur

 Lamanya :.........................................................................................................
 Keadaan waktu tidur :.......................................................................................
I. Psikososial
Perilaku ibu terhadap bayi :.......................................................................................

II. DATA OBJEKTIF

A. Pemeriksaan Fisik
Keadaan umum................................................................................................................
.........................................................................................................................................
B. Kepala
 Ubun – ubun kecil :..............................................................................................
 Caput succedenum :............................................................................................
 Chepal hematoma :..............................................................................................
 Ukuran lingkar kepala :........................................................................................
 Fronto occipito :...................................................................................................
C. Mata
 Bentuk :................................................................................................................
 Ukuran :...............................................................................................................
D. Konjungtiva
 Sclera :.................................................................................................................
 Kelnainan :...........................................................................................................
E. Hidung
 Lubang hidung :...................................................................................................
 Pernafasan cuping hidung :..................................................................................
 Secret :.................................................................................................................
 Kelainan :.............................................................................................................
F. Bibir
 Warna :.................................................................................................................
 Palatum :..............................................................................................................
 Lidah :..................................................................................................................
 Gusi :....................................................................................................................
 Refleks sucking :..................................................................................................
 Refleks rooting :...................................................................................................
G. Telinga
 Bentuk :................................................................................................................
 Letak telinga terhadap mata :...............................................................................
 Pengeluaran cairan :.............................................................................................
 Kelainan :.............................................................................................................
H. Leher
 Pembengkakan kelenjar :.....................................................................................
 Getah bening kelenjar tiroid :..............................................................................
 Reflex tonik neck :...............................................................................................
 Kelainan :.............................................................................................................
I. Dada
 Bentuk dada :.......................................................................................................
 Lingkar dada :......................................................................................................
 Tulang rusuk dan sternum :.................................................................................
J. Abdomen – Bentuk
 Keadaan tali pusat :..............................................................................................
 Perdarahan tali pusat :..........................................................................................
 Tanda – tanda infeksi :.........................................................................................
 Hernia umbilikalis :.............................................................................................
 Kelainan :.............................................................................................................
K. Genetalia
Laki – laki
 Lubang uretra :.....................................................................................................
 Testis :..................................................................................................................
Perempuan
 Labia mayora :.....................................................................................................
 Lubang vagina :...................................................................................................
 Lubang uretra :.....................................................................................................
L. Keadaan punggung
 Spina bifida :........................................................................................................
M. Anus
 Lubang :...............................................................................................................
N. Ekstremitas atas
 Gerakan tangan :..................................................................................................
 Refleks grasping :................................................................................................
 Refleks moro :......................................................................................................
 Jari –jari tangan :..................................................................................................
 Akrosianosis :......................................................................................................
O. Ekstremitas bawah
 Gerakan kaki :......................................................................................................
 Refleks babinsky :................................................................................................
 Akrosianosis :......................................................................................................
P. Kulit
 Warna kulit :........................................................................................................
 Tanda lahir :.........................................................................................................
 Kelainan :..........................................................................................................
Q. Pemeriksaan penunjang
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R. Terapi
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