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 ANAK UMUR ...............................

DENGAN .................................................

PENGKAJIAN
Tanggal/Jam Pengkajian : Mahasiswi :
No.MR/Reg :

BIODATA
a. Anak
Nama Anak : ………………………………………………………
Umur : ………………………………………………………
Jenis Kelamin : ………………………………………………………
Anak ke - : ………………………………………………………
Jumlah saudara : ………………………………………………………
b. Orang Tua
Nama ayah : Tn.……………….. Nama ibu : Ny.……………….....
Umur : ……………….. Umur : ………………...........
Agama : ......................... Agama : ..................................
Suku/Bangsa : ......................... Suku/Bangsa : ..................................
Pendidikan : ......................... Pendidikan : ..................................
Pekerjaan : ......................... Pekerjaan : ..................................
Alamat Rumah : ......................... Alamat Rumah: ...................................

A. DATA SUBJEKTIF

a. Keluhan Utama : ..............................................................................................

..............................................................................................
..............................................................................................

b. Riwayat penyakit sekarang : ..........................................................................

..........................................................................
.........................................................................

c. Riwayat Anatenatal
ANC di :
.........................................................................
ANC pertama kali :
..........................................................................
Imunisasi TT :
..........................................................................
Penyakit yang diderita selama hamil :
.............................................................

d. Riwayat Natal
Usia Kehamilan : ...............................................

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 Cara Persalinan : ...............................................
Keadaan waktu lahir : ...............................................
Tempat & penolong persalinan : ...............................................
Berat badan : ...............................................

e. Riwayat Imunisasi
BCG : ............................................................................
DPT I.II.III : ............................................................................
POLIO I,II,III,IV : ............................................................................
HEPATITIS I,II,III : ............................................................................
CAMPAK : ............................................................................

f. Riwayat Sosial
Yang mengasuh anak : ...............................................
Hubungan dengan orang tua : ...............................................
Hubungan dengan anggota keluarga : ...............................................
Hubungan dengan teman sebaya : ...............................................
Pembawaan secara umum : ...............................................

g. Pemenuhan Kebutuhan Dasar

Pola kebutuhan dasar Sebelum sakit Saat sakit

Nutrisi
o Jenis makanan
o Frekuensi makan
o Jenis minuman
o Nafsu makan
Eliminasi
o BAB
- Frekuensi
- Warna
- Bau
- Konsistensi
o BAK
- Frekuensi
- Warna
- Bau
Istirahat
o Siang
o Malam
Kebersihan diri
o Mandi
o Gosok gigi
o Ganti pakaian

B. DATA OBJEKTIF
1. Pemeriksaan Umum
 Keadaan umum :
…………………………………………………………………
 Kesadaran :
…………………………………………………………………
 Ekspresi wajah :
…………………………………………………………………
Tanda-tanda Vital
- Suhu : …..….. oC
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 - Pernapasan : ….... x per menit
- Nadi : ….... x per menit
 BB sebelum sakit : ...................................kg
 BB saat sakit : ...................................kg

2. Pemeriksaan Fisik
a. Kepala : ......................................................................
b. Wajah
 Mata : ......................................................................
 Conjungtiva : ......................................................................
 Sklera : ......................................................................
 Reaksi terhadap cahaya : .........................................................
c. Telinga
 Bersih/kotor : .........................................................
 Serumen : .........................................................
d. Mulut dan gigi
 Mukosa : .........................................................
 Lidah : .........................................................
 Karies : .........................................................
 Bibir : .........................................................
 Stomatitis : .........................................................
e. Hidung
 Pernapasan cuping hidung : ..................................................
 Polip : ..........................................................
 Sekret : ..........................................................
f. Leher
 Pembesaran kelenjar limfe dan tiroid : ....................................
g. Thoraks
 Retraksi dinding dada : .........................................................
 Ronchi : .........................................................
 Bentuk : .........................................................
h. Abdomen
 Perut kembung : ...................................................................
 Bising usus : ...................................................................
i. Ekstremitas atas dan bawah : ..................................................................
j. Turgor kulit : ...................................................................
k. Genetalia : ...................................................................

3. Therapi yang diberikan

 ...................................................
 ...................................................
 ...................................................
 ...................................................

4. Pemeriksaan penunjang
Laboratorium : ................................
 Darah..............................
 Urine...............................
 Lain-Lain.........................

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

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Pebimbing Lahan Praktik/CI Mahasiswa

(.....................................................) (.....................................................)

Mengetahui
Pembimbing Institusi/CT

(.....................................................)

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