ASUHAN KEBIDANAN PADA NEONATUS

I. PENGKAJIAN
Identitas / Biodata
Nama Bayi : ............................
Umur : ............................
Jenis Kelamin : ............................
Nama Ibu : ............................ Nama Ayah : ............................
Umur : ............................ Umur : ............................
Pekerjaan : ............................ Pekerjaan : ............................
Pendidikan : ............................ Pendidikan : ............................
Suku / Bangsa : ............................ Suku/Bangsa : ............................
Agama : ............................ Agama : ............................
Alamat : ............................

Anamnesis Pada Tanggal :...................................Pukul .................................................

Jenis Anamnesa : ......................................................
1. Keluhan Utama / Alasan Datang :
..........................................................................................................................................
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2. Riwayat Antenatal
a. G P A Ah
b. ANC : ........x di............
c. Kenaikan BB
 Sebelum hamil : .............................................................................................
 Selama Hamil :..............................................................................................
d. Riwayat Penyakit Selama Hamil :
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e. Komplikasi Ibu :
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f. Komplikasi Janin :
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 g. Kebiasaan Waktu Hamil :
1) Makanan :
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2) Obat-obatan/Jamu :
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3) Merokok :
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3. Riwayat Persalinan :
a. Umur Kehamilan : .................................................................................
b. Tanggal/jam persalinan : .................................................................................
c. Jenis Persalinan : .................................................................................
d. Lama Persalinan : .................................................................................
e. Penolong Persalinan : .................................................................................
f. Komplikasi Ibu : .................................................................................
g. Komplikasi BBL : .................................................................................
h. Bounding Attachment : .................................................................................
i. Menetek Pertama Kali : .................................................................................
j. Nilai Apgar 1/5/10
No
Kriteria 1 menit 5 menit 10 menit
.
1. Denyut jantung

2. Pernafasan

3. Tonus Otot

4. Reflek

5. Warna kulit
Jumlah

II. PEMERIKSAAN
1. Pemeriksaan Fisik Umum
a. Keadaan Umum : .............................................................................................
b. Tanda Vital
 RR : .............................................................................................
 Suhu : .............................................................................................
  Nadi : .............................................................................................
c. warna kulit : .............................................................................................
2. Antropometri
1) BB/PB/LK/LD : ............gram/..........cm/..........cm/..........cm
3. Pemeriksaan Fisik
a. Kepala
1) Muka : .............................................................................................
2) Ubun-ubun : .............................................................................................
3) Mata : .............................................................................................
4) Telinga : .............................................................................................
5) Mulut : .............................................................................................
b. Hidung : .............................................................................................
c. Leher : .............................................................................................
d. Dada : .............................................................................................
e. Abdomen : .............................................................................................
f. Punggung : .............................................................................................
g. warna kulit : .............................................................................................
h. Genetalia : .............................................................................................
i. Anus : .............................................................................................
j. Ekstremitas Atas : .............................................................................................
k. ekstremitas bawah : .............................................................................................
4. Reflek
a. R. Moro : .............................................................................................
b. R. Babynsky : .............................................................................................
c. R. Rooting : .............................................................................................
d. R. Walking : .............................................................................................
e. R.Graps : .............................................................................................
f. R. Sucking : .............................................................................................
g. R. Tonic Neck: .............................................................................................
5. Eliminasi
a. Miksi : .............................................................................................
b. Defekasi : .............................................................................................
6. Pengetahuan ibu
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7. Pemeriksaan Penunjang
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