KEMENTERIAN KESEHATAN RI

BADAN PENGEMBANGAN DAN PEMBERDAYAAN SDM KESEHATAN

POLITEKNIK KESEHATAN MATARAM
Jalan Prabu Rangkasari Dasan Cermen Cakranegara-Mataram
Telepon (0370) 631160-621383 Faximile (0370) 621383
Website: www.poltekkesmataram.ac.id, Email:admin@poltekkesmataram.ac.id

ASUHAN KEBIDANAN PATOLOGIS PADA BAYI NY “....” USIA 0 HARI

DENGAN ……………............................................
DI ..........................................................

Tanggal masuk/pukul :_______________________

No. RM :_______________________
Tempat :_______________________

I. PENGUMPULAN DATA DASAR TGL/JAM :______________________

A. Data Subyektif (S)
1. Identitas Bayi
Nama : ...........................................................................
Umur : ...........................................................................
Tanggal lahir : ...........................................................................
2. Identitas Orang Tua/Wali
Nama Klien :……………………. Nama Suami : …………………
Umur :……………………. Umur : …………………
SukuBangsa :……………………. SukuBangsa : …………………
Agama :……………………. Agama : …………………
Pendidikan :……………………. Pendidikan : …………………
Pekerjaan :……………………. Pekerjaan : …………………
Alamat lengkap :…………………………………………………………………….

3. Anamnesa
1) Keluhan utama
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
2) Riwayat Perjalanan Penyakit
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
................................................................................................................................

Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Kemenkes Mataram Angkatan Tahun 2017
Nama/Nim : /P071241170
 3) Riwayat Kehamilan
Hamil :.................................................................
Frekuensi ANC :.................................................................
Imunisasi TT :.................................................................
Kenaikan BB Hamil :.................................................................

Riwayat penyakit/kehamilan
a. Perdarahan : .............................................................
...
b. Eklamsia : .............................................................
...
c. Pre eklamsi
: ................................................................
d. Penyakit Kelamin
: ................................................................
e. Penyakit Lain
: ................................................................

Kebiasaan waktu hamil

a. Makanan : ......................................................................
b. Obat-obatan/jamu : ......................................................................
c. Merokok : ......................................................................
d. Lain-lain : ......................................................................
4) Riwayat Persalinan
a. Lama persalinan
: ......................................................................
b. Warna air ketuban
: ......................................................................
c. Jenis persalinan
: ......................................................................
d. Komplikasi Persalinan
: ......................................................................
e. Penolong : .................................................
.....................
f. Jam/tgl/lahir
: ......................................................................
g. Jenis kelamin
: ......................................................................
Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Kemenkes Mataram Angkatan Tahun 2017
Nama/Nim : /P071241170
 h. BB/PB
: ......................................................................
i. Pemberian obat : ......................................................................
j. IMD : .............................................................
.........
5) Pola KebutuhanSehari-hari
a. Nutrisi
Pemberian ASI :
Lama :
Lain-lain :
b. Eliminasi
- BAK pukul ……… Wita
Frekuensi :
Warna :
- BAB pukul ………. Wita
Frekuensi :
Warna :
Konsistensi :
B. Data Obyektif
1. Pemeriksaan Umum
Keadaan Umum : ........................................................................................
Kesadaran : ........................................................................................
2. Keadaan bayi baru lahir
1) Penilaian sepintas
a) Warna kulit :…………………
b) Tonus otot :…………………
c) Bayi menangis :…………………

Apgar Score

No Aspek yang 1 menit pertama Nilai 5 menit kedua Nilai

dinilai
1 Appearance
2 Pulserate
3 Grimace
4 Activity
5 Respiratory

3. Tanda – tanda vital : DenyutJantung : ......... x/menit

Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Kemenkes Mataram Angkatan Tahun 2017
Nama/Nim : /P071241170
 Respirasi : ......... x/menit
Suhu : ..........C
4. Pertumbuhan danAntropometri
Berat Badan :......... kg
Lingkar kepala :......... cm
Lingkar dada :......... cm
Lingkar Lengan Atas :......... cm
5. Pemeriksaan Fisik
a. Ubun- Ubun : Caput Suksedenum ( ), Chepal Hematoma ( ), UUB Datar ( ),
Molase( ), Pembengkakan ( ), Daerah Yang Cekung Pada
Kepala ( ), Kelainan ( )
b. Wajah : Simetris ( ), Kelainan ( )
c. Mata : Bersih ( ), Sclera Ikterus ( ), Infeksi ( ), Strabismus ( ),
Konjungtiva ( ), Trauma Edema Palpebra ( )
d. Telinga : Lunak ( ), Kelainan ( ), Letak Sejajar Dengan Kontus Mata ( ),
Infeksi ( )
e. Hidung : Lunak ( ), Pernapasan Cuping Hidung ( ), Sekret ( )
f. Mulut : Warna Bibir ( ), Labioskisis ( ), Sianosis ( ), Palatum
Lunak ( ), Palatoskisis ( ), Labio Genato Palatoskisis ( ),
Hipersalivasi ( ),
g. Leher : Pembengkakan Kelenjar Tiroid ( ), Tumor/Massa ( ),
Bendungan Vena Jugularis ( ), Dapat Digerakkan Kekiri Dan
Kekanan ( ),
h. Abdomen : Perdarahan Tali Pusat ( ), Jumlah Pembuluh
Darah ( ), Hernia Umbilikalis ( ), Hernia Diafragmatika ( ),
Omfalokel( ), Gastroskisis ( ), Hepatosplenomegali ( )
i. Punggung : Pembengkakan (Spina Bifida Danokulta) ( )
j. Genitalia : Jenis Kelamin( ), kelainan ( )........................................................
k. Anus : Berlubang ( )
l. Ekstremitas
Atas : Gerakan Normal ( ), Trauma Lahir ( ), Sianosis Pada Kuku ( ),
Sindaktili ( ), Polidaktili ( ), Amelia ( )
Bawah : Gerakan Normal ( ), Simetris ( ), jumlah jari normal ( ), Sianosis
Pada Kuku ( ), Sindaktili ( ), Polidaktili ( ), Amelia ( )
m. Kulit : Verniks ( ), Warna Kulit ( ), Pembengkakan ( ),Tanda Lahir ( )
3. Reflek
Reflek Moro : …………………………………………………

Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Kemenkes Mataram Angkatan Tahun 2017
Nama/Nim : /P071241170
 Reflek Rooting : …………………………………………………
Reflek Sucking : …………………………………………………
Reflek Swallowing : …………………………………………………
Reflek Grasping : …………………………………………………
Reflek tonik Neck : …………………………………………………
Reflek Galants : …………………………………………………
4. Pemeriksaan penunjang (jika dilakukan)
a. Darah tgl : ..................................
HGB : ...............................
RBC : ...............................
WBC : ...............................
PLT : ...............................
GDS : ...............................
Al : ...............................
HMT : ...............................
Golongan darah : ...............................

II. INTERPRETASI DASAR

1. Diagnosa kebidanan :
................................................................................................................................
2. Masalah :
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
3. Kebutuhan :
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
III. MENGINDENTIFIKASI DIAGNOSA/ MASALAH POTENSIAL
...........................................................................................................................................
...........................................................................................................................................
IV. KEBUTUHAN TERHADAP TINDAKAN SEGERA
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
V. RENCANA ASUHAN YANG MENYELURUH Tanggal…………… Pukul ……..Wita
1. ................................................................................
2. ................................................................................
Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Kemenkes Mataram Angkatan Tahun 2017
Nama/Nim : /P071241170
 3. ................................................................................
4. ................................................................................
5. ................................................................................
6. ................................................................................
7. ………………………………………………………….

VI. PELAKSANAAN ASUHAN Tanggal……………. Pukul ………. Wita

1. ………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

2. .................................................................................................................................
.................................................................................................................................
.................................................................................................................................
3. .................................................................................................................................
................................................................................................................................
................................................................................................................................
4. ................................................................................................................................
................................................................................................................................
................................................................................................................................
5. ................................................................................................................................
.................................................................................................................................
.................................................................................................................................
6. ................................................................................................................................
.................................................................................................................................
.................................................................................................................................
7. ................................................................................................................................
................................................................................................................................
................................................................................................................................
VII. EVALUASI Tanggal ……………, Pukul ……… Wita
1. ……………………………………………………………………………………………
2. ..............................................................................................................................
3. ..............................................................................................................................
4. ..............................................................................................................................
5. ..............................................................................................................................
6. ..............................................................................................................................
7. ..............................................................................................................................

Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Kemenkes Mataram Angkatan Tahun 2017
Nama/Nim : /P071241170
 Mengetahui,

Mahasiswa Pelaksana

( )

Pembimbing Lahan Pembimbing Pendidikan

( ) ( )

Asuhan Kebidanan BBL Patologi DIV Kebidanan Poltekkes Kemenkes Mataram Angkatan Tahun 2017
Nama/Nim : /P071241170