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
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Persalinan
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Nifas
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Tanggal
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Umur kehamilan
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Jenis persalinan
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Penolong
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Komplikasi
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JK
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BB lahir
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laktasi
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komplikasi
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5. Riwayat Imunisasi
Jenis Imunisasi
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Umur
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Tanggal Pemberian
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Tempat Pemberian
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Diberikan Oleh
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BCG
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Hepatitis B
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I :
II :
III :
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Polio
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I :
II :
III :
IV :
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DPT
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I :
II :
III :
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Campak
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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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