contoh format asuhan kebdanan pada anak

CONTOH FORMAT ASUHAN KEBIDANAN PADA ANAK

NO. REGISTER: …………………………

MASUK RS TANGGAL, JAM         : ……………………………………………………...

DIRAWAT DI RUANG                    : ...................................................................................

I.              PENGKAJIAN DATA, Oleh:..........................................Tanggal/Jam: .......................

A.    Biodata                                                    

1.       Nama bayi      : ..........................................

2.       Tanggal lahir  : ........................ jam ..........

3.       Nama  Ibu       : ..........................................    Ayah .......................................

4.       Umur              : ..........................................    .................................................

5.       Agama            : ..........................................    .................................................

6.       Suku/bangsa   : ..........................................    .................................................

7.       Pendidikan     : ..........................................    .................................................

8.       Pekerjaan        : ..........................................    .................................................

9.       Alamat           : ..........................................    .................................................

B.     Data Subjektif

1.       Riwayat kehamilan

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

Umur kehamilan         : ...................................................................................

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

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

 TT 1 tanggal .................., TT 2 tanggal .....................

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

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

Penyakit selama hamil ...................................................................................

Kebiasaan                  

·         Makan                  :

·         Obat/jamu             :

·         Merokok              :

Komplikasi

·         Ibu                        :

·         Janin                     :

2.       Riwayat persalinan

Kala II mulai tanggal : ............................... jam ................

DJJ                             :

TBJ                             :

Ketuban pecah           : lama..................... jam, warna ..................................

Vaskularisasi              : ………………………………………………...........

Caput succedaneum   : ...................................................................................

Lahir seluruhnya        : tanggal .........................jam .............

Jenis persalinan          : spontan / tindakan.....................................................

                                                              Atas indikasi .............................................................

Penolong                    : .................................. di ............................................

PB/BB lahir                : ...................................................................................

Lama persalinan         : Kala I ....................... jam ................... menit

                                     Kala II ...................... jam ................... menit

3.       Keadaan bayi baru lahir

Lahir tanggal....................................... jam ....................................................

Masa gestasi   : ................................... minggu

BB/PB lahir    :................................................................................................

Nilai APGAR : 1 menit/5 menit/10 menit/2 jam: ....... /........ /....... /........ 

No	Kriteria	1 menit	5 menit	10 menit	2 jam
1	Denyut Jantung
2	Usaha nafas
3	Tonus otot
4	Reflek
5	Warna kulit
	TOTAL

Cacat bawaan : ...............................................................................................

Resusitasi       : Penghisapan lendir    : ya/tidak

                         Ambu bag                 : ya/tidak

                         Massase jantung        : ya/tidak

C.     Data Objektif

1.       Pemeriksaan Umum

a.       Keadaan umum    : ...................................................................................

b.       Tanda vital

Tekanan darah     : ...................................................................................

Nadi                     : ...................................................................................

Pernafasan           : ...................................................................................

Suhu                     : ...................................................................................

c.       BB sekarang         : ...................................................................................

2.       Pemeriksaan Fisik

a.       Kepala                  : ...................................................................................

b.       Muka                    : ...................................................................................

c.       Ubun-ubun           : ...................................................................................

d.       Mata                     : ...................................................................................

e.       Hidung                 : ...................................................................................

f.        Telinga                 : ...................................................................................

g.       Mulut                   : ...................................................................................

h.       Leher                    : ...................................................................................

i.         Dada                    : ...................................................................................

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

k.       Abdomen             : ...................................................................................

l.         Punggung             : ...................................................................................

m.     Ekstremitas          : ...................................................................................

n.       Genetalia              : ...................................................................................

o.       Anus                    : ...................................................................................

3.       Reflek                        : Moro             : ...........................................................

  Rooting         : ...........................................................

  Walking         : ...........................................................

  Graphs           : ...........................................................

  Sucking         : ...........................................................

  Tonicneck      : ...........................................................

4.       Antropometri             : LK     : .................. cm

  LD     : .................. cm

  LK     : .................. cm

5.       Eliminasi

Miksi                           : ...................................................................................

Defekasi                      : ...................................................................................

6.       Pemeriksaan Penunjang

a.       Pemeriksaan Laboratorium

Darah, tanggal:               

Hemoglobin         : .................. gr%         (Normal: ......... - ............)

Hematokrit           : ..................                 (Normal: ......... - ............)

Golongan darah   : ..................

Bilirubin               : ..................                (Normal: ......... - ............)

GDS                     : ..................                (Normal: ......... - ............)

b.       Pemeriksaan penunjang lain: .......................... Tanggal ..........................

Hasil: ....................................................................................................................................................................................................................................

c.       Catatan Medik lain

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

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

II.           INTERPRETASI DATA

A.    Diagnosa kebidanan

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

Data Dasar:

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

B.     Masalah

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

Data Dasar:

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

C.     Kebutuhan

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

Data Dasar:

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

III.         IDENTIFIKASI DIAGNOSA/MASALAH POTENSIAL DAN ANTISIPASI PENANGANAN

A.    Diagnosa Potensial

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

Data Dasar:

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

B.     Masalah Potensial

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

Data Dasar:

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

C.     Antisipasi

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

IV.        MENETAPKAN KEBUTUHAN TERHADAP TINDAKAN SEGERA BERDASARKAN KONDISI KLIEN

A.    Mandiri

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

B.     Kolaborasi

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

C.     Merujuk

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

V.           RENCANA ASUHAN YANG MENYELURUH, tanggal ............................jam .......

VI.        IMPLEMENTASI

Tanggal ............................... jam ..........                                                           

VII.      EVALUASI

Tanggal ............................... jam ..........