Senin, 13 Mei 2013

Format askeb tumbuh kembang


FORMAT ASUHAN KEBIDANAN PADA
TUMBUH KEMBANG BALITA

No.Register                             : ..............................
Masuk tanggal                         : ..............................                            Jam : ..............
Dirawat diruang                      : ..............................                                                               

I.  PENGKAJIAN                                         Tanggal : ...........         Jam :........        Oleh : ............
A. DATA SUBJEKTIF
1. Biodata
Identitas  Anak
Nama                        : .............................
Tanggal Lahir,jam    : .............................
Jenis kelamin            : .............................
Anak ke                    : .............................
                                
 Identitas Orang Tua
                                               Ibu                                          Suami
Nama                        : .............................                              ...............................
Umur                        : .............................                              ...............................
Agama                      : .............................                              ...............................
Suku / bangsa           : .............................                              ...............................
Pendidikan               : .............................                              ...............................
Pekerjaan                  : .............................                              ...............................
Alamat                     : .............................                              ...............................

2. Alasan masuk
            .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Keluhan Utama
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................





4. Riwayat kehamilan/persalinan
Hamil ke
Persalinan
Nifas
Tanggal
Umur kehamilan
Jenis persalinan
Penolong
Komplikasi
JK
BB lahir
laktasi
komplikasi




















































5. Riwayat  Imunisasi
Jenis Imunisasi
Umur
Tanggal Pemberian
Tempat Pemberian
Diberikan Oleh
BCG





Hepatitis B

I    :
II   :
III :


Polio

I    :
II  :
III :
IV :


DPT

I    :
II  :
III :


Campak





          

6. Riwayat Penyakit Keluarga
a.    Menular  
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
b.    Menurun
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
c.    Menahun   
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
7.  Riwayat penyakit anak
Sekarang     :
a.    Menular         
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
b.    Menurun
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
c.    Menahun    
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
  
8.  Kebutuhan sehari-hari
a.    Pola nutrisi                                      
                            Makan                                              Minum
Frekuensi   : ......................x/hari                         ..............................x/hari
Macam       : ......................                                  ..............................
Jumlah        : ......................                                  ..............................
Pantangan  : ......................                                  ..............................
Keluhan     : ......................                                  ..............................
                      
b.   Pola  Eliminasi
                            BAK                                                BAB
Frekuensi   : ......................x/hari                         ..............................x/hari               
Warna        : ......................                                  ..............................                        
Bau                                                              : ......................                     ..............................
Konsistensi                                                  : ......................                     ..............................
Keluhan     : ......................                                  ..............................

c.    Pola Istirahat
                            Siang                                                Malam
Frekuensi   : .....................jam/hari                       .............................jam/hari
Keluhan     : ....................                                     .............................

d.   Personal hygine
Mandi        : ............................x/hari
Gosok gigi                                                   : ............................x/hari
Keramas     : ............................x/hari
        

9.  Riwayat Menyusui
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................


B. DATA OBYEKTIF                                   Tanggal:...........   Jam:..........    Oleh:.............. 
1.  Pemeriksaan  umum
a.    Keadaan umum
Kesadaran         : ....................

b.    Antropometri              
Lingkar Kepala                         : .....................
Panjang Badan  : .....................       
LILA                 : .....................                               
Berat Badan      : .....................       
Lingkar Dada    :.................                                              
                                        
c.    Tanda-tanda Vital                         
Nadi                  : .....................                         
Pernapasan        : .....................        
Suhu                  : .....................                      

2.  Pemeriksaan Fisik
a.    Kepala              
Rambut             : .....................
Muka                 : ....................
Bentuk               : ....................
Odema               : ....................
Massa                : ....................

b.    Mata                                                                     
Bentuk mata      : .....................                            
Strabismus         : .....................
Sklera                : .....................
Keadaan            : .....................

c.    Hidung                
Pernafasan cuping hidung   : .........................
Keadaan                               : .........................
Lubang hidung                   : .........................
Pembesaran polip                 : ........................

d.   Mulut            
Bentuk              : ........................
Gusi                   : ........................
Refleks hisap     : ........................
Karies                : ........................
Stomatitis          : ........................

e.    Telinga                                                                 
Kesimetrisan    : ........................
Keadaan            : ........................
 Berlubang         : ........................

f.     Leher                                                                    
Pembesaran vena : .......................

g.    Dada                                                                    
Denyut jantung : .......................x/menit
Mamae              : ........................
Pernafasan         : ........................
Retraksi             : ........................
h.    Abdomen                                                             
Bentuk                                                                  : ........................
Dinding perut    : ........................
Inspeksi             : ........................
Palpasi               : ........................
Kembung          : ........................
Bising usus        : ........................

i.      Genetalia          
Jenis kelamin     : ........................
Perempuan         : ........................
Laki-laki            : ........................

j.      Anus                                                                    
Lubang anus      : ........................
Keadaan            : ........................
Hemoroid          : ........................
Tulang belakang : ......................

k.    Kulit                      
Warna                : ........................

l.      Ekstremitas      
Atas                  
Jari tangan              : ........................
Posisi dan bentuk   : ........................
Pergerakan             : ........................




Bawah :
Jari kaki               : ........................
Posisi dan bentuk                                             : ........................
Pergerakan           :  ........................                 
Reflek Patella      : ........................
               
3.  Pemeriksaan  khusus
a.  Pertumbuhan
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

 b. Perkembangan
Personal sosial       : ........................
Motorik halus        : ........................
Bahasa                   : ........................
Motorik kasar        : ........................
Tes perilaku           : ........................
                                                 
II.  INTERPRESTASI DATA                                        
1.      Diagnosa  kebidaan
................................................................................................................................................................................................................................................................................................
2.      Masalah
................................................................................................................................................................................................................................................................................................

III. DIAGNOSA POTENSIAL
............................................................................................................................................................................................................................................................................................................................................................................................................................................................
IV.  ANTISIPASI TINDAKAN SEGERA
Mandiri : ............................................................................................................................................................................................................................................................................................................................................................................................................................................................
Kolaborasi : ............................................................................................................................................................................................................................................................................................................................................................................................................................................................
Rujukan : ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................
               
V.   PERENCANAAN
............................................................................................................................................................................................................................................................................................................................................................................................................................................................

VI. PELAKSANAAN            
...........................................................................................................................................................................................................................................................................................................................................................................................................................................................                                              
VII. EVALUASI                                                                   
............................................................................................................................................................................................................................................................................................................................................................................................................................................................

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