No.

Target :

ASUHAN KEBIDANAN PADA BAYI BARU LAHIR

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

Tanggal/Jam Pengkajian :
Tempat Pengkajian :
No Register :

I. Pengkajian
A. Data Subyektif
1. Identitas Bayi
Nama :
Usia :
Tanggal lahir :
2. Identitas Penanggung jawab (Ibu dan Ayah)
Ibu Ayah
Nama : ......................................... Nama : ...............................................
Usia : ......................................... Usia : ...............................................
Agama : ......................................... Agama : ...............................................
Pendidikan : ......................................... Pendidikan : ..............................................
Pekerjaan : ......................................... Pekerjaan : ..............................................
Suku/Bangsa : ........................................ Suku/Bangsa : ..............................................
Alamat : ........................................
No. Telepon : ........................................ No. Telepon :..............................................
3. Riwayat Antenatal
G...............P..........A..........
Masa Kehamilan.............................................minggu
Riwayat ANC : teratur/tidak ;..................kali, di......................oleh....................
Imunisasi TT............................kali
Keluhan saat hamil : ................................................................................................
Penyakit Selama Hamil : ................................................................................................
Kebiasaan Saat Hamil : ................................................................................................
a. Makanan : ............................................................................................................

b. Obat/jamu : ............................................................................................................

c. Merokok : ............................................................................................................

d. Lain-Lain

Komplikasi kehamilan :

Komplikasi janin :..................................................................................................

4. Riwayat Persalinan
a. Lama Kala I
b. Lama Kala II
c. Warna air ketuban
d. Jumlah air kebutan
e. Jenis persalinan
f. Penolong
g. Jam/ tanggal lahir
h. Kaput
i. Komplikasi persalinan
j. Komplikasi pada bayi
: ................................................................................................
: ................................................................................................
: ................................................................................................
: ................................................................................................
: ................................................................................................
: ................................................................................................
: ................................................................................................
: ................................................................................................
: ............................................................................................
: ............................................................................................
 5. Keadaan Bayi Baru Lahir
a. Nilai APGAR

No. Kriteria 1 Menit 5 Menit 10 Menit

1 Activity
2 Pulse
3 Grimace
4 Appearance
5 Respirations
Total

b. Resusitasi

a) Rangsangan : ya/tidak

b) Penghisapan Lendir : ya/tidak

c) Ambu bag : ya/tidak...................liter/menit

d) Masase jantung : ya/tidak

e) Intubasi endotrakeal : ya/tidak

f) O2 : ya/tidak....................liter/menit

B. Data Obyektif
1. Pemeriksaan Umum

KU : ..............................................................................................

Kesadaran : ..............................................................................................

Tanda vital : T.................; N.....................x/mnt; S......................0C; R............x/mnt

2. Pemeriksaan Fisik

a. Kepala : .........................................................................................................
.........................................................................................................
b. Muka : .........................................................................................................
c. Ubun-ubun : .........................................................................................................
d. Mata : .........................................................................................................
e. Telinga : .........................................................................................................
f. Hidung : .........................................................................................................
 g. Mulut : .........................................................................................................
.........................................................................................................
h. Leher : .........................................................................................................
i. Dada : .........................................................................................................
.........................................................................................................
j. Tali pusat : .........................................................................................................
k. Abdomen : .........................................................................................................
l. Genitalia : .........................................................................................................
.........................................................................................................
m. Anus : .........................................................................................................
n. Ekstremitas : .........................................................................................................
.........................................................................................................
.........................................................................................................

3. Pemeriksaan Neurologis

a. Refleks Moro : ..................................................................................

b. Refleks rooting : ..................................................................................
c. Refleks berjalan : ..................................................................................
d. Refleks menggengam : .............................................................................
e. Refleks menghisap :
f. Refleks tonik leher :

4. Antopometri

a. Lingkar Kepala...................................................cm
b. Lingkar dada.......................................................cm
c. Lingkar lengan atas.............................................cm
d. Panjang badan.....................................................cm
e. Berat badan.........................................................Kg

5. Eliminasi

a. Miksi : ................................................................................................
b. Defekasi : ................................................................................................
 6. Pemeriksaan Penunjang

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

II. INTERPRETASI DATA

A. Diagnosa Kebidanan

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

Data Subyektif:
.........................................................................................................................................................
.......................................................................................................................................................
.............................................................................................................................
Data Obyektif
.............................................................................................................................
.............................................................................................................................

B. Masalah

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

Data Subyektif :
.....................................................................................................................................................
...................................................................................................................................................

Data Obyektif
.....................................................................................................................................................
...................................................................................................................................................
.........................................................................................................................
 C. Masalah

.....................................................................................................................................................
...................................................................................................................................................
.........................................................................................................................
Data Subyektif :
.....................................................................................................................................................
...................................................................................................................................................
.........................................................................................................................
Data Obyektif
.....................................................................................................................................................
...................................................................................................................................................

III. LANGKAH III (ANTISIPASI DIAGNOSA ATAU MASALAH POTENSIAL)

IV. LANGKAH IV (IDENTIFIKASI KEBUTUHAN TINDAKAN SEGERA)

V. LANGKAH V (PLANNING/ INTERVENSI)

No Planning Rasional
VI. LANGKAH VI (IMPLEMENTASI)

Tgl/jam Tindakan
VII.LANGKAH VII (EVALUASI)

Tanggal / Pukul :

S :

O:

A :

P :
 LEMBAR KONSULTASI
Nama Mahasiswa :
Nim :
Judul Asuhan :

Hari/Tanggal Revisi Tanda Tangan