ASUHAN KEBIDANAN NEONATUS

Ruang : ............................
Tanggal : ..............................

I. PENGKAJIAN
Identitas/Biodata
Nama bayi : .............................
Umur : .............................
Jenis kelamin : .............................
Nama Ibu : ............................ Nama Suami : .............................
Umur : ............................. : .............................
Pendidikan : ............................. : .............................
Pekerjaan/Penghasilan ............................. : .............................
Suku/Bangsa : ............................. : .............................
Agama : ............................. : .............................
Alamat : ............................. : .............................

Anamnesa pada tanggal .....................................................................Pukul .........................

Jenis anamnesa : ........................................................

1. Keluhan utama/Alasan datang:

................................................................................................................................................
..............................................................................................................................
2. Riwayat Antenatal
a. G....P....A....Ah....
b. ANC : Teratur/Tidak Teratur, .......x di...........
c. Kenaikan BB selama hamil ...............................
3. Riwayat Kehamilan dan Persalinan saat ini:
a. Para : A: Hidup :
b. Masa Gestasi : ......................................................................................................
c. Kelaianan selama hamil : ....................................................................................
d. Tanggal persalinan : ....................................................................................
e. Tempat persalinan : ....................................................................................
f. Penolong persalinan : ....................................................................................
g. Jenis persalinan : ....................................................................................
h. Ketuban pecah : ....................................................................................
i. Lama persalinan : ....................................................................................
 j. Perdarahan : .................................................................................
...
k. Penyulit dalam persalinan : ....................................................................................
l. Plasenta : ....................................................................................
m. Perineum : ....................................................................................
n. Anak : .................., BB :...............gram, PB:..............cm,
Kelainan bawaan: .......................................................................................................
o. Obat-obat yang diperoleh selama nifas: .....................................................................
4. Rawat gabung: .........., alasan: ..............................................................................................
5. Riwayat perkawinan :
a. Status perkawinan : .......................................................
b. Usia pertama kali menikah : .......................................................
c. Berapa kali menikah : .......................................................
d. Lama menikah dengan suami sekarang : .......................................................
e. Anak dari pernikahan yang sekarang atau yang lalu : ..................................................
6. Riwayat kesehatan :
a. Riwayat kesehatan sekarang:
..........................................................................................................................................
..........................................................................................................................................
....................................................................................................................................
b. Riwayat kesehatan yang lalu
: .................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
...
c. Riwayat kesehatan keluarga
: .................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
...
7. Riwayat obstetrik yang lalu:

Komplikasi
Tgl Bayi nifas
persalinan
Penyulit lahir/ Jenis Tempat Penolong
No PB/BB, Ke
kehamilan umur persalinan persalinan persalinan Keadaa Laktas
Kelami ada
anak n i
n an

1.
8. Riwayat KB :

Jenis/Sejak Lama Penggunaan Keluhan Alasan Berhenti

9. Pola Pemenuhan Kebutuhan Sehari-hari:

pantangan atau
Kebutuhan Keluhan
kekhawatiran

Nutrisi :
 Makan
(.................................................................)
 Minum
(................................................................)
Eliminasi :
 BAK
(................................................................)
 BAB
(................................................................)
Istirahat
(................................................................
................................................................)

Aktifitas
(................................................................)

Personal Hygien
(................................................................
................................................................)

Rekreasi
(................................................................)

Pola Seksual
(................................................................)
10. Data Psikologis :
a. Tanggapan ibu atas kelahiran bayinya/jenis kelamin bayinya:
....................................................................................................................................
b. Perasaan ibu atas peran barunya :
....................................................................................................................................
c. Perasaan ibu terhadap penampilan diri di hadapan suami:
....................................................................................................................................
d. Keyakinan ibu atas kemampuan menjadi ibu :
....................................................................................................................................
e. Tanggapan keluarga atas kelahiran bayinya:
....................................................................................................................................
f. Tanggapan anak sebelumnya atas kelahiran bayinya:
....................................................................................................................................
g. Rencana ibu menyusui bayinya:
....................................................................................................................................
11. Data Sosial-Budaya :
a. Hubungan dengan suami, dan anggota keluarga lain:
....................................................................................................................................
b. Hubungan dengan tetangga:
....................................................................................................................................
c. Hewan peliharaan: .....................................................................................................
d. Lingkungan: ..............................................................................................................
e. Adat/tradisi/kebiasaan dalam masa nifas bagi ibu dan bayi: ....................................
12. Data spiritual : .....................................................................................................
13. Pengetahuan ibu :
a. Masa nifas : .....................................................................................................
b. Nutrisi & cairan : .....................................................................................................
c. Mobilisasi/latihan/senam: ..............................................................................................
d. Eliminasi: .....................................................................................................
e. Hygiene diri dan perineum: ...........................................................................................
f. Istirahat: .....................................................................................................
g. Seksualitas: ...................................................................................................
h. Kontrasepsi: .....................................................................................................
i. Tanda bahaya masa nifas.................................................................................................
j. Jadwal kunjungan: .....................................................................................................
14. Pengetahuan tentang bayi:
a. Tentang menyusui/makanan bayi:
 i. Manfaat ASI :
.............................................................................................................................
ii. Makanan bati ( ASI eksklusif):
............................................................................................................................
iii. Perawatan payudara:
...............................................................................................................................
iv. Teknik menyusui dengan benar ( 1 atau 2 bayi):
............................................................................................................................
f. Tentang bayi:
i. Perawatan bayi sehari-hari:
.............................................................................................................................
ii. Imunisasi dasar bayi:
............................................................................................................................
iii. Metode pencegahan hipotermi:
............................................................................................................................
II. PEMERIKSAAN UMUM
1. Pemeriksaan umum
a. Keadaan Umum : ......................................................................................................
b. Kesadaran : ......................................................................................................
c. Status Emosional : ......................................................................................................
d. Tanda vital :
 TD : ......................................................................................................
 Nadi : ......................................................................................................
 RR : ......................................................................................................

 Suhu : ......................................................................................................

e. Status present
 Kepala
 Rambut : .........................................................................................
 Muka : .........................................................................................
 Mata : .........................................................................................
 Hidung : .........................................................................................
 Telinga : .........................................................................................
 Mulut : .........................................................................................
 Leher : .....................................................................................................
 Dada : .....................................................................................................
 Mammae : .....................................................................................................
  Perut : .....................................................................................................
 Genetalia : .....................................................................................................
 Ekstremitas
 Atas : .....................................................................................................
 Bawah : .....................................................................................................
2. Pemeriksaan Obstetri
 Wajah/muka : .....................................................................................................

 Payudara:
1. Bentuk : .....................................................................................................
2. Putting : .....................................................................................................
3. Pengeluaran: .....................................................................................................
4. Pembengkakan: ..................................................................................................
5. Lain-lain: .....................................................................................................
 Abdomen:
a) Tinggi fundus uteri: .........................................................................................
b) Kontraksi uterus: .............................................................................................
c) Palpasi supra publik/kandung kemih: ..........................................................
d) Lain-lain: .....................................................................................................
 Pengeluaran pervaginam:
a) Warna lochea : ................................................................................................
b) Banyaknya: .....................................................................................................
c) Bau: .....................................................................................................
d) Lain-lain: .....................................................................................................
 Perineum dan anus:
a) Luka episiotomi/jahitan: .................................................................................
b) Keadaan luka: .................................................................................................
c) Tanda radang: .................................................................................................
d) Keadaan vulva: ...............................................................................................
e) Anus: .....................................................................................................
2. Pemeriksaan Penunjang / laboratorium
a. Protein urin : .....................................................................................................
b. Urin reduksi : .....................................................................................................
c. HB : .....................................................................................................
d. Terapi : .....................................................................................................