1 Format Laporan

Askeb pada Bayi & Balita

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No. Register : ………………………….

Masuk RS tanggal / jam : ………………………….
Dirawat diruang : ………………………….

I. PENGKAJIAN Tanggal : ...................., Jam : ...............WIB, Oleh : ...........................…......

A. DATA SUBJEKTIF
1. Biodata
a. Identitas Bayi/Balita
Nama : ...................................................
Umur : ...................................................
Jenis kelamin : ...................................................

b. Identitas Orang Tua

Ibu Ayah
Nama : ................................................... ................................................
Umur : ................................................... ................................................
Agama : ................................................... ................................................
Suku/Bangsa : ................................................... ................................................
Pendidikan : ................................................... ................................................
Pekerjaan : ................................................... ................................................
Alamat : ................................................... ................................................
No. Telp : ................................................... ................................................

2. Alasan Masuk/ Kunjungan

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3. Keluhan Utama
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4. Riwayat Antenatal
a. G ........ P .......... A .......... Ah ...............
b. Riwayat ANC : teratur/tidak, ......... kali, di ..................... oleh .........
c. Imunisasi TT : .......... kali
d. Kenaikan BB : .......... kg
e. Keluhan : ..............................................................................................
f. Penyakit selama hamil : ..............................................................................................
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g. Kebiasaan : ..............................................................................................
(makan, minum obat/jamu) ..............................................................................................
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h. Komplikasi
 Ibu : ..............................................................................................
 Janin : ..............................................................................................

Program Studi D III Kebidanan UNRIYO T.A 2011/2012

2 Format Laporan
Askeb pada Bayi & Balita

5. Riwayat Intranatal
a. Lahir tanggal : ............................... jam : .................... WIB
b. Usia gestasi : .................. minggu
c. Jenis persalinan : ..............................................................................................................
d. Penolong/tempat : ..............................................................................................................
e. Komplikasi
 Ibu : ..............................................................................................................
 Janin : ..............................................................................................................

6. Riwayat Kesehatan
a. Penyakit yang pernah/sedang diderita (menular, menurun dan menahun)
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b. Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan menahun)
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c. Riwayat rawat inap & operasi
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d. Riwayat alergi makanan/obat
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7. Riwayat Imunisasi
Jenis Tanggal Pemberian
BCG
Hepatitis B
Polio
DPT
Campak

8. Pola Pemenuhan Kebutuhan Sehari-hari

a. Nutrisi
Makan Minum
Frekuensi : ............................. Frekuensi : .............................
Jenis : ............................. Jenis : .............................
Porsi : ............................. Porsi : .............................
Pantangan : ............................. Pantangan : .............................
Keluhan : ............................. Keluhan : .............................
b. Eliminasi
BAB BAK
Frekuensi : ............................. Frekuensi : .............................
Warna : ............................. Warna : .............................
Konsistensi : ............................. Konsistensi : .............................
Keluhan : ............................. Keluhan : .............................
c. Istirahat
Tidur siang Tidur malam
Lama : ............................. Lama : .............................
Keluhan : ............................. Keluhan : .............................

Program Studi D III Kebidanan UNRIYO T.A 2011/2012

3 Format Laporan
Askeb pada Bayi & Balita

B. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan Umum : ....................................
Tanda-Tanda Vital : S : ...........0c N : .......... x/menit R : .......... x/menit
PB : ................cm BB : ............... gram

2. Pemeriksaan fisik
a. Kepala
Bentuk : ..............................................................................................................
Rambut : ..............................................................................................................
Muka : ..............................................................................................................
Mata : ..............................................................................................................
Hidung : ..............................................................................................................
Mulut : ..............................................................................................................
Telinga : ..............................................................................................................
Lingkar kepala : ......... cm
b. Leher : ..............................................................................................................
c. Dada
Bentuk : ..............................................................................................................
Puting : ..............................................................................................................
Gerakan : ..............................................................................................................
Payudara : ..............................................................................................................
Paru-Paru : ..............................................................................................................
Jantung : ..............................................................................................................
Lingkar dada : ............ cm
d. Abdomen
Bentuk : ..............................................................................................................
Dinding Perut : ..............................................................................................................
Tali pusat : ..............................................................................................................
Palpasi : ..............................................................................................................
Perkusi : ..............................................................................................................
Auskultasi : ..............................................................................................................
e. Ekstremitas atas : .................................................................................. LILA : ..........cm
f. Ekstremitas bawah : ..............................................................................................................
g. Genetalia
Laki-Laki : ..............................................................................................................
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Perempuan : ..............................................................................................................
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h. Anus : ..............................................................................................................
Mekonium : ..............................................................................................................
i. Punggung : ..............................................................................................................
j. Kulit
: ..............................................................................................................

3. Pemeriksaan khusus
Personal sosial : ..........................................................................................................................
Motorik halus : .........................................................................................................................
Motorik kasar : .........................................................................................................................
Bahasa : .........................................................................................................................

Program Studi D III Kebidanan UNRIYO T.A 2011/2012

4 Format Laporan
Askeb pada Bayi & Balita

II. INTERPRETASI DATA

A. Diagnosa kebidanan
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Data Dasar:
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B. Masalah
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Data Dasar:
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III. IDENTIFIKASI DAN ANTISIPASI DIAGNOSA POTENSIAL

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IV. TINDAKAN SEGERA

A. Mandiri
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B. Kolaborasi
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C. Merujuk
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V. PERENCANAAN Tanggal : …………………. ……. Pukul : ……….....WIB

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VI. PELAKSANAAN Tanggal: .......................................... Pukul : ................WIB

Program Studi D III Kebidanan UNRIYO T.A 2011/2012
5 Format Laporan
Askeb pada Bayi & Balita

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VII. EVALUASI Tanggal : ........................................... Pukul : .......... .....WIB

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Pembimbing Institusi Pembimbing Lapangan Mahasiswa

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Program Studi D III Kebidanan UNRIYO T.A 2011/2012

6 Format Laporan
Askeb pada Bayi & Balita

Contoh S O A P

Subyektif
Menurut ibu usia kehamilan cukup bulan yaitu 40 minggu

Obyektif
Tanggal 10 Maret 2014 Bayi perempuan lahir spontan tidak menangis
tonus otot lemah, warna kulit biru

Asesmen / Diagnosa
Neonatus Cukup Bulan dengan asfiksia

Pelaksanaan

1. Menginformasikan hasil pemeriksaan dan asuhan yang akan

diberikan,keluarga mengerti
2. Melakukan Resusitasi langkah awal,bila bayi belum menangis lakukan
VTP dengan memberikan oksigen.Bila resusitasi sudah 2 menit belum
menangis bayi segera dirujuk ke RS.
3. Memantau tanda bahaya pasca resusitasi bila bayi bisa menangis hasil
terlampir.
4. Memfasilitasi IMD,berhasil pada menit ke 51

Program Studi D III Kebidanan UNRIYO T.A 2011/2012