ASUHAN KEBIDANAN PADA BAYI BARU LAHIR

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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
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 : ........
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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.
  LLA : .................. cm
Circum Ferensia......................
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
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II. INTERPRETASI DATA
A. Diagnosa kebidanan
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Data Dasar:
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B. Masalah
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Data Dasar:
.............................................................................................................................................................................................................................................................. Kebutuhan
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Data Dasar:
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III. IDENTIFIKASI DIAGNOSA/MASALAH POTENSIAL DAN ANTISIPASI PENANGANAN
A. Diagnosa Potensial
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Data Dasar:
.............................................................................................................................................................................................................................................................. Masalah Potensial
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Data Dasar:
.............................................................................................................................................................................................................................................................. Antisipasi
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IV. MENETAPKAN KEBUTUHAN TERHADAP TINDAKAN SEGERA BERDASARKAN KONDISI KLIEN
A. Mandiri
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B. Kolaborasi
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C. Merujuk
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V. RENCANA TINDAKAN, tanggal ............................jam .......
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VI. IMPLEMENTASI Tanggal ............................... jam ..........
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VII. EVALUASI Tanggal ............................... jam ..........
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