ASUHAN KEBIDANAN PADA BAYI BARU LAHIR

No. Medrec :..................................

Tgl Masuk :..................................
Tgl & Jam Pengkajian :..................................
Tempat Pengkajian :..................................
Nama Pengkaji :..................................

A. DATA SUBJEKTIF
IDENTITAS
1. Bayi
Nama : ……………………………………………
Umur : ……………………………………………
Tanggal/jam lahir : ……………………………………………

2. Orang tua
IBU AYAH

Nama : ................................................... ......................................................

Umur : ...................................................
Suku : ...................................................
Agama : ...................................................
Pendidikan : ...................................................
Pekerjaan : ...................................................
Alamat : ...................................................
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No.Telepon : ...................................................
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1. Alasan datang ke RS
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2. Keluhan Utama
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3. Riwayat Antenatal
G…..P…..A…….. Umur kehamilan ………………
Riwayat ANC : ……………………………………….
Status Imunisasi Ibu : ……………………………………….
Kenaikan BB : ……………………………………….
Keluhan saat hamil : ……………………………………….
 Penyakit saat hamil : ……………………………………….
Kebiasaan Sehari-hari : ……………………………………….
4. Riwayat pesalinan sekarang
Jenis persalinan : ……………………………………….
Tempat persalinan : ……………………………………….
Penolong persainan : ……………………………………….
Lama persalinan : Kala I :
……………………………………….
Kala II : ……………………………………….
Kala III : ……………………………………….
Ketuban pecah : ……………………………………….
Komplikasi ibu : ……………………………………….
Komplikasi janin : ……………………………………….
5. Keadaan bayi baru lahir
Warna kulit : ……………………………………….
Tangisan : ……………………………………….
Pernafasan : ……………………………………….
Tonus otot : ……………………………………….
Resusitasi : ……………………………………….
Penghisapan lendir : ……………………………………….
Ambu bag : ……………………………………….
O2 : ……………………………………….
Cacat bawaan : ……………………………………….

B. DATA OBJEKTIF
1. Keadaan Umum : ....................................................................................................
Kesadaran : ....................................................................................................
Antropometri :
BB : ....................................................................................................
PB : ....................................................................................................
LK : ....................................................................................................
LD : ....................................................................................................
Lila : ....................................................................................................

Tanda-tanda vital
Nadi : ..................... x/mnt
Suhu : .....................0C
Respirasi : ..................... x/mnt

2. Kepala
Bentuk : ....................................................................................................
Ubun-ubun besar : ....................................................................................................
Ubun-ubun kecil : ....................................................................................................
CaputSucadaneum: ....................................................................................................
Cephal Hematoma: ....................................................................................................
Sutura : ....................................................................................................
Kelainan : ....................................................................................................
3. Mata
Bentuk : ....................................................................................................
Konjungtiva : ....................................................................................................
Sklera : ....................................................................................................
Refleks Pupil : ....................................................................................................
Reflex glabella : ....................................................................................................
Pengeluaran : ....................................................................................................

4. Telinga
Bentuk : ....................................................................................................
Lubang telinga : ....................................................................................................
Daun telinga : ....................................................................................................
Pengeluaran : ....................................................................................................

5. Hidung
Bentuk : ....................................................................................................
Lubang hidung : ....................................................................................................
Pengeluaran : ....................................................................................................
Pernafasan cuping hidung :…………………………………………………………

6. Mulut dan faring

Bentuk : ....................................................................................................
Labioskizis : ....................................................................................................
Labiopalatoskizis : ....................................................................................................
Refleks Sucking : ....................................................................................................
Refleks Swalowing: ...................................................................................................
Reflex Rooting : ....................................................................................................

7. Leher
Pembengkakan : ....................................................................................................
Benjolan : ....................................................................................................
Refleks Tonik Neck: ..................................................................................................
Kelainan : ....................................................................................................

8. Dada
Bentuk : ....................................................................................................
Bunyi nafas : ....................................................................................................
Retraksi : ....................................................................................................
Bunyi jantung : ....................................................................................................
Kelainan : ....................................................................................................

9. Abdomen
Bentuk : ....................................................................................................
Penonjolan tali pusat
: ........................................................................................
Perdarahan tali pusat : ........................................................................................
Keadaan tali pusat : ........................................................................................
 10. Punggung
Bentuk : ....................................................................................................
Cekungan/Pembengkakan : ...........................................................................
Kelainan : ....................................................................................................
Reflex Galant : ....................................................................................................

11. Ekstremitas
Atas : Gerakan : ............................................................................
Jumlah jari : ............................................................................
Kelainan : ............................................................................
CRT : ............................................................................
Reflex Graps : ............................................................................
Refleks Moro : ............................................................................
Bawah : Gerakan : ............................................................................
Jumlah jari : ............................................................................
Kelainan : ............................................................................
CRT : ............................................................................
Reflex Plantar : ............................................................................
Refleks Babinski : ............................................................................

12. Genitalia
Laki-laki
Testis dan Skrotum : ........................................................................................
Penis : ........................................................................................
Pengeluaran : ........................................................................................
Kelainan : ........................................................................................

Perempuan
Labia : ........................................................................................
Uretra : ........................................................................................
Pengeluaran : ........................................................................................
Kelainan : ........................................................................................

13. Kulit
Warna : ........................................................................................
Tanda Lahir : ........................................................................................
Verniks :………………………………………………………….
Lanugo :………………………………………………………….
Kelainan : ........................................................................................

C. ANALISA
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D. PENATALAKSANAAN
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Bidko Pelaksana Asuhan

Titin Sumartini, Amd.Keb Sri Sintawati, Amd.Keb

NIP.197503252003122003 NIP.198611102017042006

Mengetahui
Kepala Puskesmas Kabandungan

H. SUPRAPTO, SKM
NIP.196706241990031008