YAYASAN SAMODERA ILMU CENDEKIA

STIKES BORNEO CENDEKIA MEDIKA

Jl. Sultan Syahrir No. 11 Pangkalan Bun Kab. Kotawaringin Barat Kalteng Kode Pos 74112
Telp. (0532) 28200, 082234971000, e-mail : stikesbcm15@gmail.com

FORMAT ASUHAN KEBIDANAN PADA ANAK/BALITA

NAMA MAHASISWA :……………………………………………………………………

NIM :……………………………………………………………………
SEMESTER :……………………………………………………………………

Tanggal masuk RS/Poli/Puskesmas :……………………………………………………………………

Jam :……………………………………………………………………
Tanggal Pengkajian :……………………………………………………………………
Jam :…………………………………………………………………….
Nomor registrasi pasien :…………………………………………………………………….
Nomor tempat tidur :……………………………………………………………………
Diagnosa masuk :…………………………………………………………………….

1. PENGKAJIAN
A. Data Subyektif
1. Identitas (Biodata)
a. Identitas Bayi
Nama Bayi : …………………...........................................................
Umur : …………………...........................................................
Jenis Kelamin : …………………...........................................................
Agama : …………………...........................................................
Alamat : .………………………………………………………..

b. Identitas Orang Tua

Nama Ibu :………………… Nama Ayah :…………………
Umur :………………… Umur :…………………
Suku/Bangsa :………………… Suku/Bangsa :…………………
Agama :…………………. Agama :…………………
Pendidikan :…………………. Pendidikan :………………….
Pekerjaan :…………………. Pekerjaan :………………….
Nomor Telepon :…………………. Nomor Telepon :………………….
Alamat Rumah :…………………. Alamat Rumah :………………….

2. Riwayat Kesehatan
- Riwayat Kesehatan Saat Ini : …………………………………………………
- Riwayat Kesehatan Sebelumnya
a. Panyakit yang pernah dialami :
…………………………………………………
Cacar ( ) Pernah ( ) tidak pernah
Polio ( ) Pernah ( ) tidak pernah
Difteri ( ) Pernah ( ) tidak pernah
Tetanus( ) Pernah ( ) tidak pernah
Pertusis( ) Pernah ( ) tidak pernah
Thypoid Fever ( ) Pernah ( ) tidak pernah
TBC ( ) Pernah ( ) tidak pernah
Varicella ( ) Pernah ( ) tidak pernah
Hepatitis ( ) Pernah ( ) tidak pernah
Morbili ( ) Pernah ( ) tidak pernah
Lainnya :…………………………………………………………………

b. Pernah Dirawat di Rumah Sakit : ( ) ya ( ) tidak

c. Kecelakaan :…………………………………………………………
 d. Jenis Obat yang digunakan:…………………………………………………….

3. Riwayat Kehamilan dan Kelahiran

a. Selama Kehamilan : ………………………………………………………..
b. Saat Kelahiran : ………………………………………………………..
c. Setelah Kelahiran : ………………………………………………………..

4. Riwayat Imunisasi
No Jenis Tanggal I Tanggal II Tanggal III Tanggal IV
1 Hepatitis B
2 BCG
3 DPT-HB-HIB
4 Polio
5 Campak
6 MMR
7 Meningitis

5. Riwayat Pertumbuhan Fisik

Miring : ……………………………………………………………………
Tengkurap : ……………………………………………………………………
Merangkak : ……………………………………………………………………
Tumbuh gigi pertama : ……………………………………………………………………
Berdiri : ……………………………………………………………………
Berjalan : ……………………………………………………………………

6. Riwayat Pertumbuhan Psikososial Spritual

a. Pola Interaksi dengan orang lain : ………………………………………………
b. Pola Interaksi dengan saudara kandung/teman : ………………………………………
c. Pembawaan anak secara umum : ………………………………………………
d. Pola Kultural : ………………………………………………

7. Pola Kebiasaan/Pemenuhan Kebutuhan Sehari- Hari

a. Pola Nutrisi dan cairan
Pola Makan : ……………………………………………………………..
Makanan Pokok : ……………………………………………………………..
Makanan yang disukai : ……………………………………………………………..
Makanan yang tidak disukai: …………………………………………………………..
Porsi : ……………………………………………………………..
Lauk Pauk : ……………………………………………………………..
Sayuran dan Buah : ……………………………………………………………..
Minum : ……………………………………………………………..
Nafsu Makan : ……………………………………………………………..

b. Pola Tidur : ……………………………………………………………

c. Pola Eliminasi : ……………………………………………………………..
d. Pola Hygiene Tubuh : ……………………………………………………………..
e. Pola Aktivitas : ……………………………………………………………..

B. Data Obyektif
1. Antropometri
Tinggi Badan : …………………………………………………………………….
Berat Badan : …………………………………………………………….............
Lingkar Kepala : ……………………………………………………………............
LILA : ……………………………………………………………............

2. Keadaan Umum : ……………………………………………………………...............

Kesadaran : ……………………………………………………………...............
 3. Tanda-Tanda Vital
- Suhu : ….......................................................................................ᵒC
- Nadi : ….......................................................................................x/menit
- Pernafasan : ….......................................................................................x/menit

4. Pemeriksaan Fisik :
Kepala : ...................................................................................................................
Wajah : simetris : ……………...
paralysis sub facial : ………….......
down syndrom : ………….......
Mata : simetris : ……………...
Secret : ……………...
Conjunctiva : ……………...
Sclera : ……………...
reaksi pupil : ……………...
Hidung : simetris : ………..…….
Polip : ……………...
Sekret : ……………...
Mulut : bibir simetris : …………....... Palatum mole : .........................
Warna : ……….…...... Palatum durum: ........................
Labiopalatoskisis : ……………... Lidah : .........................
Trush : ……….…......
Telinga : daun telinga : …...................
Simetris : …...................
Leher : bentuk : …...................
gerakan baik : …...................
Dada : simetris : ................…...
areola mamae : ................…...
papila mamae : …...................
ronchi : ..................….
retraksi : ...............…....
Perut : bentuk : …...................
hernia difragmatika : ..................….
hepatosplenomegali : ..............….....
bising usus : ....................…
Punggung : bentuk : ...............…....
spina bifida : …...................
Ekstrimitas : Atas : simetris : .......................
jumlah jari lengkap: ......................
Bawah : simetris : ....................
jumlah jari lengkap : ....................
Kulit : ..................................................................................................................................
Anogenital : Laki-laki : testis :…...................
Anus : ...…...............
Perempuan : labia mayora menutupi labia minora : …...................
pengeluaran :…....................
anus : .......................

5. Pemeriksaan penunjang lain :………………………………………………………………

II. INTERPRETASI DATA/ ANALISA DATA

Diagnosis Kebidanan : ...........................................................................................................

Masalah : ...........................................................................................................
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III. IDENTIFIKASI DIAGNOSA MASALAH POTENSIAL

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IV. IDENTIFIKASI KEBUTUHAN SEGERA

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V. INTERVENSI
Tanggal :.......................................Jam............................
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VI. IMPLEMENTASI

Tanggal : ..........................................., Jam : .....................

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VII. EVALUASI
Tanggal : ......................................, Jam : ..............................
S : ..............................................................................................................................
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O : ..............................................................................................................................
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