LAPORAN

ASUHAN KEBIDANAN PADA BAYI / BALITA / ANAK PRASEKOLAH

An.........Umur....th, dengan kebutuhan....................
Di.......................................................

I. PENGKAJIAN

Tanggal :..................................

Waktu :..................................

Tempat :..................................

II. IDENTITAS

a. Identitas Bayi
Nama :..............................

Tanggal/Jam lahir :..............................

Jenis kelamin :..............................

b. Identitas Orang tua

Nama ibu: Nama suami:

Umur: Umur:

Agama: Agama:

Pendidikan: Pendidikan:

Pekerjaan: Pendidikan:

Alamat: Alamat:

III. DATA SUBYEKTIF

1. Alasan Datang :.........................

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

2. Riwayat Kesehatan:

Dahulu :.........................................
 Sekarang :......................................

Keluarga:........................................

3. Riwayat kehamilan, persalinan dan nifas:

Dahulu:………………………………………

Sekarang:…………………………………….

4. Riwayat tumbang: (Disertai dengan hasil penilaian KPSP)

Pertumbuhan BB:…………………………..

Perkembangan anak:..........................

Kelainan bawaan:................................

5. Riwayat Imunisasi :...................................

6. Pola kebiasaan sehari- hari:

Pola nutrisi:...............................................

Pola eliminasi:..........................................

Pola istirahat:...........................................

Pola aktifitas:..........................................

Personal hygiene:....................................

Pola Sosial Ekonomi:........................................

IV. DATA OBYEKTIF

1. Pemeriksaan Umum:

Keadaan umum:

Kesadaran:

Vital signs: N =................x/mnt

 RR = ..................x/mnt

T = ..................x/mnt

2. Pengukuran antropometri:

BB : KG Lingkar kepala/ LK : CM

PB : CM LILA : CM

3. Status Present:

Kepala :...............................

Muka :...............................

Mata :...............................

Hidung :................................

Mulut :.............................

Telinga :...............................

Leher :.............................

Dada :............................

Pulmo/COR :.............................

Abdomen :................................

Genetalia :...............................

Punggung :..............................

Anus :..................................

Ekstremitas :...........................

Kulit :................................

V. ANALISA : …………………………………………………
VI. PENATALAKSANAAN (TANGGAL…….JAM……)

1. .............................................................................................................................................................
Hasil : .........................................................................................................................................................
2............................................................................................................................................................
Hasil : .........................................................................................................................................................
3 ..............................................................................................................................................................
Hasil : ........................................................................................................................................................

CATATAN: Untuk pengkajian perkembangan bayi/balita/anak pra sekolah sertakan KPSP NYA

Semarang, .......................2017

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