LAPORAN ASUHAN KEPERAWATAN

BAYI BARU LAHIR

BIDAN PRAKTIK MANDIRI YESI RAHMAWATI
 LAPORAN ASUHAN KEPERAWATAN
BAYI BARU LAHIR
BIDAN PRAKTIK MANDIRI YESI RAHMAWATI

Kelompok 3:
Dhea Februliza Mylanda
Egi Amanda Liesty
Emilia Adeline Clara Septiana
Erlita Saktiyani
Fadila Agustin
Lekok Ermawati
Nena Melinda
Putri Naura Sakhi
Rola Sintia Putri
Tandok Andani
Tara Febru Dinanti
Wayan Intan Kartini
Yuni Purnama sari

PROGRAM STUDI D III KEPERAWATAN

POLTEKKES TANJUNGKARANG
2022
A. PENGKAJIAN BAYI BARU LAHIR Tanggal Pegkajian : 11-03-2022
Ruangan : BPM Yesi Rahmawati

DATA UMUM
Inisial ibu : Ny. M Nama Ayah : Tn. S
Alamat : Dusun Ranji Rt 01.RW 01
Riwayat kehamilan, persalinan dan nifas yang lalu

No Tahun Jenis Penilong Jenis Keadaan Masalah

persalina bayi kehamila
n n

- - - - - - -
Status gravida
G 1 P 0 A 0 H...............Presentasi bayi....................
Pemeriksaan antenatal : teratur/tidak teratur
Komplikasi antenatal : ........................................

RIWAYAT PERSALINAN
BB/TB ibu : 63 kg/ 155 cm, persalinan di BPM Yesi Rahmawati
Keadaan ibu : Composmentis
TTV : TD : 120/mmHg N : 80x/menit RR : 24x/menit S : 36 derajat
Jenis persalinan : Spontan proses persalinan Normal.
Kala I : 6 jam
Indikasi : - Kala II 15 menit
Komplikasi persalinan : Ibu nyeri Janin tak
Lamanya ketuban pecah : 15 menit Kondisi ketuban keruh
Keadaan bayi saat lahir :
Lahir tanggal : 11 maret.jam 21.45 sex jenis kelamin
Kelahiran : tunggal/gemeli
 Penilaian apgar
Tanda 0 1 2 Jumlah total

Frekuensi Tidak ada < 100 x / menit > 100 x / menit 2

denyut jantung

Usaha nafas Tidak ada Lambat Menangis kuat 2

Tonus otot Lumpuh Ekstremitas Gerakan aktif 2

fleksi sedikit

Refleks Tidak beraksi Gerakan Reaksi 2

sedikit melawan

Warna kulit Biru atau pucat Tubuh Kemerahan 2

kemerahanTan
gan dan kaki 10 > normal
biru
Tindakan resusitasi : Tidak Ada
Plasenta berat : . ± 500 gr tali pusat panjang. ± 50.cm
Ukuran : 20x20x2 cm Jumlah pembuluh darah 1 vena 2 arteri
Kelainan : tidak ada
 
Pengkajian fisik
Umur - hari. 2 jam. 30 menit
BB 3100 gr
PB 47 cm
Suhu 36,5 derajat C
Lingkar kepala 31 cm
Lingkar dada. 33 cm
Lingkar perut 35 cm
Kepala
Bentuk : bulat, dll
Molding, kaput, cephal hematom
Ubun-ubun besar :
Besar ada
Kecil ada
Sutura tidak ada
Mata
Posisi: simetris
Kotoran: ada sedikit pada mata bayi
Perdarahan: tidak ada

Telinga
Posisi: simetris
Bentuk: sama antara kanan dan kiri
Lubang telinga: besih
Keluaran: tidak ada sekret

Mulut
Simetris: simetris kanan dan kiri
Palatum mole: dbm
Palatm durum: dbm
Gigi: belum ada gigi

Hidung
Lubang hidung: terdapat 2 lubang
Keluaran:tidakada sekret
Pernafasan cuping: tidak ada
Lanugo: masih tampak diarea atas dada, punggung, lengan atas, Kaki
Vernik: Tersisa sedikit ditubuh bayi
Mekonium: Sudah keluar
Punggung
Keadaan punggung :
Simetris/asimetris/pilonidal dimple

Fleksibilitas
Tulang punggung : kelainan: tidak ada
Genitalia : normal/hipospadius/epispadius
Testis..............
Vagina : normal
(menonjol/tertutup labia mayora, keluaran)
Anus : Kelainan: tidak ada
Ekstremitas :
Jari tangan : kelainan : normal
Jari kaki : kelainan : normal
Pergerakan : tidak aktif/asimetris/tremor/rotasi paha/aktif
Nadi : Brachial: normal
Femoral : normal
Garis telapak kaki: terdapat garis telapak kaki
Posisi
Kaki: simetris sama panjang
Tangan : simetris sama panjang
Data yang menunjang
Lab
Leher : Pergerakan leher: normal
Tubuh: tidak ada pembengkakakn vena
Warna : Pink/pucat/sianosis/kuning
Pergerakan
Aktif/kurang
Dada : Simetris/asimetris/retraksi
Jantung & paru-paru : Normal/ngorok, dll
Pernafasan 30x/menit
Denyut jantung 130x/menit
Perut: normal
Lembek/kembung/benjolan
Bising usus: 12x/menit
Psikososial: baik
Kesimpulan : hasil pengkajian bayi Normal
masalah : Resiko defisit nutrisi
Penyebab : -
-
2. Risiko infeksi ditandai dengan adanya
luka pada tali pusat, efek prosedur
invasive

3. Risiko defisit nutrisi ditandai dengan

reflek hisap tidak adekuat,
ketidakmampuan mengabsorbsi
nutrient.
 What about these percentages?

70% 78%
Mercury Mars
Mercury is the Despite being red,
closest object to Mars is a cold
the Sun place

50% 65%
Venus Saturn
Venus is the Is composed of
second planet hydrogen and
from the Sun helium
 Multimedia

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 Perhaps you could use four columns

Mercury Venus Mars Saturn

Mercury is the Venus is the Despite being It’s composed
closest object to second planet red, Mars is a of hydrogen
the Sun from the Sun cold place and helium
Awesome
words
A picture always
reinforces the
concept
Images reveal large amounts
of data, so remember: use an
image instead of long texts
 Bibliographical references

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● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher
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