YAYASAN MARANATHA

NUSA TENGGARA TIMUR

SEKOLAH TINGGI ILMU KESEHATAN MARANATHA
Jl. KAMP. BAJAWA NASIPANAF - BAUMATA BARAT–KAB. KUPANG
Telp/Fax : 0380 – 8552971 ; admin@stikesmaranathakupang.ac.id
Website : http//www.stikesmaranathakupang.ac.id

ASUHAN KEBIDANAN PADA BAYI CUKUP BULAN

DI ..................................................

PENGKAJIAN
Tanggal/Jam : ………………….......................................
Mahasiswa : ……………………………………………
No.MR/Reg : ……………………………………………
A. DATA SUBYEKTIF
1. IDENTITAS BAYI
Nama Bayi : …………………………………………….
Jenis kelamin : …………………………………………….
Tanggal lahir : …………………………………………….
Jam : ………………………………………….....
Anak Ke : …………………………………………….

2. IDENTITAS ORANG TUA

Nama Ibu : …………………… Nama Ayah : ……………………….…..
Umur : …………………… Umur : ……………………..……..
Pendidikan : …………………… Pendidikan : ……………………………
Pekerjaan : …………………… Pekerjaan :………………………….....
Penghasilan : ................................ Penghasilan : ............................................
Agama : …………………… Agama : ……………………………
Alamat : …………………… Alamat : …………………………....
Suku/Bangsa :……………………. Suku/ Bangsa :…………………………….

3. RIWAYAT ANTE NATAL :

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4. RIWAYAT NATAL :
 Usia Kehamilan :
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 Cara Persalinan :
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 Lama Persalinan :
 Kala I :
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 Kala II :
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 Kala III :
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Kala IV :
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 Keadaan saat lahir
 A/S : ………………
 LK : ………............
 BB : ………….Gram
 LD : ………............
 PB : ………….. Cm
 LP : ………………
 Tempat dan Penolong persalinan :
………………………………………………………

B. DATA OBYEKTIF:
1. Pemeriksaan Umum :
 Keadaan Umum : ………………………
 Kesadaran : ……………………….
 Tanda-tanda Vital : S:…°C , RR/HR :……x/……x/mnt, BB :…….Gram
2. Pemeriksaan Fisik :
 Kepala : ………………………………………………………………....
 Mata :………………………………………………………………….
 Hidung :….………………………………………………………………
 Mulut : …………………………………………………………………
 Telinga : .………………………………………………………………...
 Leher : …………………………………………………………………
 Dada :……………………………………………………………….....
 Abdomen : …………………………………………………………………
 Tali pusat : …………………………………………………………………
 Kulit : ………………………………………………………....
 Ekstremitas atas : ………………………………………………………....
 Ekstremitas bawah : ……………………………………………………........
 Genitalia : ………………………………………………………....
 Anus : ………………………………………………………....
 Refleks :
 Morro : …………………..
 Rotting : …………………...
 Sucking : …………………...
 Swallowing :...............................
 Babynski :...............................
 Tonic neck :...............................
3. Eliminasi :
 BAB :
 Frekuensi : …………………. x sehari
 Warna : ………………………..
 Bau : ………………………..
 BAK :
 Frekuensi : ……………x sehari
 Warna : ……………………….
 Bau : ……………………….
4. Therapi : ……………………………………………………..……………..……

……………………………………………………………..……………
.

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 5. Pemeriksaan Penunjang
 Darah :……………………………………………………
 Urine :……………………………………………………
 USG :……………………………………………………
 Rontgen :……………………………………………………

C. ANALISA DATA
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D. PENATALAKSANAAN (Perencanaan, Pelaksanaan dan Evaluasi)

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Pebimbing Lahan Praktik/CI Mahasiswa

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Mengetahui

Pembimbing Institusi/CT

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