FORMAT ASKEB TUMBANG

ASUHAN KEBIDANAN TUMBUH KEMBANG PADA

BAYI/ANAK USIA.....TAHUN DI RB.......

No. Register                            : ………………………….

Masuk RS tanggal / jam          : ………………………….

Dirawat diruang                      : ………………………….

I.    PENGKAJIAN   Tanggal : ...................., Jam : ...............WIB, Oleh : ...........................…......

A.  DATA SUBJEKTIF

1.                  Biodata

a.                Identitas Bayi/Balita

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

Umur                           : ...................................................                  

Jenis kelamin               : ...................................................

b.                Identitas Orang Tua

                                                Ibu                                                       Ayah

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

Umur                           : ...................................................       ................................................

Agama                         : ...................................................       ................................................

Suku/Bangsa               : ...................................................       ................................................

Pendidikan                  : ...................................................       ................................................

Pekerjaan                     : ...................................................       ................................................

Alamat                         : ...................................................       ................................................

No. Telp                      : ...................................................       ................................................

2.                  Alasan Masuk/ Kunjungan

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

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

3.                   Keluhan Utama

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

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

4.                  Riwayat Antenatal

a.    G ........ P .......... A .......... Ah ...............

b.    Riwayat ANC                    : teratur/tidak, ......... kali, di ..................... oleh .........

c.    Imunisasi TT                       : .......... kali

d.   Kenaikan BB                      : .......... kg

e.    Keluhan                              : ..............................................................................................

f.     Penyakit selama hamil        : ..............................................................................................

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

g.    Kebiasaan                           : ..............................................................................................

(makan, minum obat/jamu)  ..............................................................................................

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

h.    Komplikasi                        

·      Ibu                                 : ..............................................................................................

·      Janin                               : ..............................................................................................

                

5.                  Riwayat Intranatal

a.    Lahir tanggal          : ...............................               jam      : .................... WIB

b.   Usia gestasi             : .................. minggu

c.    Jenis persalinan       : ..............................................................................................................

d.   Penolong/tempat     : ..............................................................................................................

e.    Komplikasi                        

·      Ibu                     : ..............................................................................................................

·      Janin                   : ..............................................................................................................

6.     Riwayat Kesehatan

a.    Penyakit yang pernah/sedang diderita (menular, menurun dan menahun)

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

b.    Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan menahun)

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

c.    Riwayat rawat inap & operasi

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

d.   Riwayat alergi makanan/obat

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

7.    Riwayat Imunisasi

Jenis	Tanggal Pemberian
BCG
Hepatitis B
Polio
DPT
Campak

8.    Pola Pemenuhan Kebutuhan Sehari-hari

a.    Nutrisi

Makan                                                                  Minum

Frekuensi              : .............................                 Frekuensi         : .............................

Jenis                     : .............................                 Jenis                : .............................

Porsi                     : .............................                 Porsi                : .............................

Pantangan                        : .............................                 Pantangan       : .............................

Keluhan                : .............................                 Keluhan           : .............................

b.    Eliminasi

BAB                                                                     BAK

Frekuensi              : .............................                 Frekuensi         : .............................

Warna                   : .............................                 Warna              : .............................

Konsistensi           : .............................                 Konsistensi      : .............................

Keluhan                : .............................                 Keluhan           : .............................

c.    Istirahat

Tidur siang                                                           Tidur malam

Lama                    : .............................                 Lama               : .............................

Keluhan                : .............................                 Keluhan           : .............................

B.                         DATA OBYEKTIF

1. Pemeriksaan umum

Keadaan Umum          : ....................................                     

Tanda-Tanda Vital      : S : ...........⁰c               N : .......... x/menit       R : .......... x/menit

PB                               : ................cm             BB : ............... gram

2.  Pemeriksaan fisik

a.                 Kepala                              

            Bentuk                         : ..............................................................................................................

            Rambut                        : ..............................................................................................................

            Muka                           : ..............................................................................................................

            Mata                            : ..............................................................................................................

            Hidung                        : ..............................................................................................................

            Mulut                          : ..............................................................................................................

            Telinga                        : ..............................................................................................................

Lingkar kepala             : ......... cm

b.                Leher                                 : ..............................................................................................................

c.                Dada                          

            Bentuk                                    : ..............................................................................................................

            Puting                          : ..............................................................................................................

            Gerakan                       : ..............................................................................................................

            Payudara                     : ..............................................................................................................

            Paru-Paru                    : ..............................................................................................................

            Jantung                        : ..............................................................................................................

            Lingkar dada               : ............ cm

d.               Abdomen                   

Bentuk                         : ..............................................................................................................

Dinding Perut              : ..............................................................................................................

Tali pusat                     : ..............................................................................................................

            Palpasi                         : ..............................................................................................................

            Perkusi                        : ..............................................................................................................

            Auskultasi                   : ..............................................................................................................

e.    Ekstremitas atas          : .................................................................................. LILA : ..........cm

f.     Ekstremitas bawah       : ..............................................................................................................

g.    Genetalia                    

Laki-Laki                    : ..............................................................................................................

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

Perempuan                  : ..............................................................................................................

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

h.    Anus                            : ..............................................................................................................

Mekonium                   : ..............................................................................................................

i.      Punggung                    : ..............................................................................................................

j.                  Kulit                            : ..............................................................................................................

3.  Pemeriksaan khusus/Pemeriksaan Penunjang

a.   Pertumbuhan

1)      Status Gizi Normal :............................................................................................................

2)      Status Gizi Kurang :............................................................................................................

3)      Status Gizi Buruk   :...........................................................................................................

4)      Status Gizi Lebih    :............................................................................................................

b. Perkembangan

1)      Personal Sosial :...............................................................................................................

2)      Motorik Halus  :...............................................................................................................

3)      Bahasa              :...............................................................................................................

4)      Motorik Kasar  :...............................................................................................................

           

II.      INTERPRETASI DATA

A.    Diagnosa kebidanan

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

Data Dasar:

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

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

B.     Masalah

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

Data Dasar:

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

III.        IDENTIFIKASI DAN ANTISIPASI DIAGNOSA POTENSIAL

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

IV.        TINDAKAN SEGERA

A.       Mandiri

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

B.        Kolaborasi

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

C.        Merujuk

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

V.           PERENCANAAN       Tanggal : …………………. …….     Pukul : ……….....WIB

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

VI.        PELAKSANAAN        Tanggal: ..........................................   Pukul : ................WIB

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

VII.     EVALUASI                 Tanggal : ........................................... Pukul : .......... .....WIB

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

Pembimbing Institusi .............................................

Mahasiswa .............................................

Pembimbing Lapangan .............................................

 

ASUHAN KEBIDANAN PADA

BAYI  DENGAN  IMUNISASI DPT-HB..........DI RB.......

No. Register                            : ………………………….

Masuk RS tanggal / jam          : ………………………….

Dirawat diruang                      : ………………………….

I.    PENGKAJIAN  Tanggal : ...................., Jam : ...............WIB, Oleh : ...........................…......

B.   DATA SUBJEKTIF

9.                  Biodata

c.                 Identitas Bayi/Balita

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

Umur                           : ...................................................                  

Jenis kelamin               : ...................................................

d.                Identitas Orang Tua

                                                Ibu                                                       Ayah

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

Umur                           : ...................................................       ................................................

Agama                         : ...................................................       ................................................

Suku/Bangsa               : ...................................................       ................................................

Pendidikan                  : ...................................................       ................................................

Pekerjaan                     : ...................................................       ................................................

Alamat                         : ...................................................       ................................................

No. Telp                      : ...................................................       ................................................

10.              Alasan Masuk/ Kunjungan

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

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

11.               Keluhan Utama

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

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

12.              Riwayat Antenatal

i.      G ........ P .......... A .......... Ah ...............

j.      Riwayat ANC                    : teratur/tidak, ......... kali, di ..................... oleh .........

k.    Imunisasi TT                       : .......... kali

l.      Kenaikan BB                      : .......... kg

m.  Keluhan                              : ..............................................................................................

n.    Penyakit selama hamil        : ..............................................................................................

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

o.    Kebiasaan                           : ..............................................................................................

(makan, minum obat/jamu)  ..............................................................................................

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

p.    Komplikasi                        

·      Ibu                                 : ..............................................................................................

·      Janin                               : ..............................................................................................

                

13.              Riwayat Intranatal

f.    Lahir tanggal          : ...............................               jam      : .................... WIB

g.   Usia gestasi             : .................. minggu

h.   Jenis persalinan       : ..............................................................................................................

i.     Penolong/tempat     : ..............................................................................................................

j.     Komplikasi                        

·      Ibu                     : ..............................................................................................................

·      Janin                   : ..............................................................................................................

14.                         Riwayat Kesehatan

a.    Penyakit yang pernah/sedang diderita (menular, menurun dan menahun)

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

b.    Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan menahun)

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

c.    Riwayat rawat inap & operasi

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

d.   Riwayat alergi makanan/obat

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

15.                        Riwayat Imunisasi

Jenis	Tanggal Pemberian
BCG
Hepatitis B
Polio
DPT
Campak

16.                        Pola Pemenuhan Kebutuhan Sehari-hari

d.   Nutrisi

Makan                                                                  Minum

Frekuensi              : .............................                 Frekuensi         : .............................

Jenis                     : .............................                 Jenis                : .............................

Porsi                     : .............................                 Porsi                : .............................

Pantangan                        : .............................                 Pantangan       : .............................

Keluhan                : .............................                 Keluhan           : .............................

e.    Eliminasi

BAB                                                                     BAK

Frekuensi              : .............................                 Frekuensi         : .............................

Warna                   : .............................                 Warna              : .............................

Konsistensi           : .............................                 Konsistensi      : .............................

Keluhan                : .............................                 Keluhan           : .............................

f.     Istirahat

Tidur siang                                                           Tidur malam

Lama                    : .............................                 Lama               : .............................

Keluhan                : .............................                 Keluhan           : .............................

B.                         DATA OBYEKTIF

1. Pemeriksaan umum

Keadaan Umum          : ....................................                     

Tanda-Tanda Vital      : S : ...........⁰c               N : .......... x/menit       R : .......... x/menit

PB                               : ................cm             BB : ............... gram

2.  Pemeriksaan fisik

k.                Kepala                              

            Bentuk                         : ..............................................................................................................

            Rambut                        : ..............................................................................................................

            Muka                           : ..............................................................................................................

            Mata                            : ..............................................................................................................

            Hidung                        : ..............................................................................................................

            Mulut                          : ..............................................................................................................

            Telinga                        : ..............................................................................................................

Lingkar kepala             : ......... cm

l.                  Leher                                 : ..............................................................................................................

m.              Dada                          

            Bentuk                                    : ..............................................................................................................

            Puting                          : ..............................................................................................................

            Gerakan                       : ..............................................................................................................

            Payudara                     : ..............................................................................................................

            Paru-Paru                    : ..............................................................................................................

            Jantung                        : ..............................................................................................................

            Lingkar dada               : ............ cm

n.                Abdomen                   

Bentuk                         : ..............................................................................................................

Dinding Perut              : ..............................................................................................................

Tali pusat                     : ..............................................................................................................

            Palpasi                         : ..............................................................................................................

            Perkusi                        : ..............................................................................................................

            Auskultasi                   : ..............................................................................................................

o.    Ekstremitas atas          : .................................................................................. LILA : ..........cm

p.    Ekstremitas bawah       : ..............................................................................................................

q.    Genetalia                    

Laki-Laki                    : ..............................................................................................................

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

Perempuan                  : ..............................................................................................................

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

r.     Anus                            : ..............................................................................................................

Mekonium                   : ..............................................................................................................

s.     Punggung                    : ..............................................................................................................

t.                 Kulit                            : ..............................................................................................................

3.  Pemeriksaan khusus/Pemeriksaan Penunjang

a.   Pertumbuhan

5)      Status Gizi Normal :............................................................................................................

6)      Status Gizi Kurang :............................................................................................................

7)      Status Gizi Buruk   :...........................................................................................................

8)      Status Gizi Lebih    :............................................................................................................

b. Perkembangan

5)      Personal Sosial :...............................................................................................................

6)      Motorik Halus  :...............................................................................................................

7)      Bahasa              :...............................................................................................................

8)      Motorik Kasar  :...............................................................................................................

           

VIII.       INTERPRETASI DATA

A.    Diagnosa kebidanan

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

Data Dasar:

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

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

B.     Masalah

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

Data Dasar:

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

IX.        IDENTIFIKASI DAN ANTISIPASI DIAGNOSA POTENSIAL

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

X.           TINDAKAN SEGERA

A.       Mandiri

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

B.        Kolaborasi

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

C.        Merujuk

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

XI.        PERENCANAAN       Tanggal : …………………. …….     Pukul : ……….....WIB

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

XII.     PELAKSANAAN        Tanggal: ..........................................   Pukul : ................WIB

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

XIII.  EVALUASI                 Tanggal : ........................................... Pukul : .......... .....WIB

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

Pembimbing Institusi .............................................

Mahasiswa .............................................

Pembimbing Lapangan .............................................