KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENKES MALANG

JURUSAN KEBIDANAN
PROGRAM STUDI SARJANA TERAPAN KEBIDANAN KEDIRI
Jl. KH. Wakhid Hasyim No. 64 B Telp. (0354) 773095 – 772833
Website : http://www.poltekkes-malang.ac.id Fax. (0354) 778340
Email : direktorat@poltekkes-malang.ac.id Kediri 64114

FORMULIR ASUHAN KEBIDANAN PADA ANAK SEHAT

Nama Mahasiswa : ……………………………………………

NIM/ Semester : …………………………………………….
Tanggal Pengkajia/Jam : ………………………………………………
No. Reg : ………………………………………………
Ruangan : ………………………………………………
Dx. Medis : ………………………………………………

I. PENGKAJIAN
A. DATA SUBYEKTIF
1. Identitas Anak :
Nama : …………………………………………………………….
Umur/Tgl lahir : …………………………………………………………….
Jenis Kelamin : …………………………………………………………….
Anak ke : …………………………………………………………….

2. Identitas Orang tua :

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

Nama Ayah : …………………………………………………………….

Umur : …………………………………………………………….
Suku Bangsa : …………………………………………………………….
Agama : …………………………………………………………….
Pendidikan : …………………………………………………………….
Pekerjaan : …………………………………………………………….
Penghasilan : …………………………………………………………….
Alamat Rumah : …………………………………………………………….
Lampiran 10
ANAMNESIS
Sumber Informasi : Keluarga Lain-lain
a. Keluhan utama
……………………………………………………………………………….
………………………………………………………………………………….
………
b. Riwayat kesehatan ibu
a. HPHT :…………… Usia kehamilan:……… minggu
b. Riwayat penyakit keturunan:
………………………………………………….
c. Riwayat antenatal
Dokter Bidan Puskesmas Rumah sakit
Lain-lain
Berapa kali :………………………….x
d. Riwayat persalinan
……………………………………………………………………………
….………………………………………………………………………..
e. Riwayat persalinan dan kehamilan terdahulu :
…………………………………
f. Penyakit ibu selama hamil :
…………………...............................................
g. Kebiasaan merokok :………………………………………………
h. Kebiasaan minum jamu :………………………………………………

c. Riwayat Natal
a. Proses kelahiran : Spontan Seksio Caesaria
Tindakan lain
b. Berat lahir:………….gram
Panjang Lahir :………cm Lika :………….cm
c. Imunisasi yang diberikan :
…………………………………………………..
d. Kelainan yang dikemukakan :
………………………………………………….
e. Riwayat Tumbuh Kembang :
………………………………………………….
f. Post Natal :
……………………………………………………………………
g. Imunisasi :
…………………………………………………………………….
 h. Riwayat kesehatan keluarga : Contreng di kolom yang sesuai
YA TIDA YA TIDA Sebutkan
K K

DM HIPERTENSI Lain-
lain

TBC HEPATITIS Lain-

lain

B. DATA OBYEKTIF
a. Keadaan umum :
Suhu :
Nadi :
Pernafasan :
Tekanan Darah :
Berat Badan :
Panjang Badan :
Lingkar Kepala :
Lingkar Lengan :
Lingkar Perut :
Lingkar Dada :
BAB :……… BAK :…… Muntah :………
Regurgitasi :………
b. Kesadaran
( ) gerak aktif ( ) menangis kuat ( ) letargi ( ) merintih
( ) coma ( ) lain-lain
c. Kepala
I. Rambut
Tipis ya/tidak Kering ya/tidak
Kotor ya/tidak Jarang ya/tidak
II. Mata
Konjungtiva Anemis ya/tidak Merah ya/tidak
Sclera ichterus ya/tidak lain-lain ya/tidak
III. Wajah
Ichterus ya/tidak grimace ya/tidak
Pucat ya/tidak cyanisus ya/tidak
Lain-lain
IV. Telinga
Simetris ya/tidak radang ya/tidak
Secret ada/tidak perdarahan ya/tidak
Tulang rawan +/-
Lain-lain: ………….
 V. Hidung
Pernafasan cuping hidung ya/tidak
Lain-lain: ………………..
VI. Mulut
Bibir kering ya/tidak trismus ya/tidak
Lidah kotorya/tidak lain-lain :…………
VII. Leher
Pembesaran vena ada/tidak kaku kuduk ada/tidak
d. Thorak
Gerak nafas : Relaksi otot dada normal/tidak
Bunyi nafas : rochi ya/tidak wheezing ada/tidak
Bentuk : Normal Chest Barel Chest
Irama Nafas : Regular Irregular
Stridor
Jantung : Regular Irregular
Murmur Irama Galop
e. Abdomen
Inspeksi :Bentuk : Buncit/Tegang/Normal
Acites : ada/tidak
Tali pusat : ……………………
Palpasi : Massa Ada/tidak
Fecalit Ada/tidak
Distensi Ada/tidak
Pembesaran hepar Ada/tidak
Perkusi : Thyampany Hypertimpany
Dulnes Lain-lain
Auskultasi : peristaltic usus……………..x/menit
f. Genetalia
Labia : oedema ya/tidak
Perdarahan ya/tidak
Labia mayor menutup labia minor iya/tidak
Scrotum : oedema ya/tidak
Sudah turun/belum
g. Anus :
Berlubang : iya/tidak
Perdarahan : iya/tidak
Lain-lain :…………………..
h. Ekstremitas
Atas : polydaktili ya/tidak
Syndaktili ya/tidak
Gerak aktif ya/tidak
Fraktur ya/tidak
Bawah : polydaktili ya/tidak
Syndaktili ya/tidak
 i. Neurologi :
Ya Tidak Ya Tidak
Kaku Kejang
Kuduk
Muntah Panas

j. Pemeriksaan Penunjang
Laborat :
Foto :
Lain-lain:
k. Perkembangan
a. Motorik Kasar
………………………………………………………………………
Motorik Halus
………………………………………………....................................
b. Bicara dan Bahasa …………………………………………………………...
………
d. Social Kemandirian
………………………………………………….......................

C. ANALISIS
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D. PENATALAKSANAAN
Tanggal : ........................ Jam : ............................
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Kediri,............................
Pembimbing Praktik Mahasiswa

.................................................... ......................................................
NIP. NIM.

Dosen Pembimbing

....................................................
NIP.