Health Ambassadors: format askeb pada bayi baru lahir

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:

B. Masalah

Data Dasar:

III. IDENTIFIKASI DIAGNOSA/MASALAH POTENSIAL DAN ANTISIPASI PENANGANAN

A. Diagnosa Potensial

Data Dasar:

IV. MENETAPKAN KEBUTUHAN TERHADAP TINDAKAN SEGERA BERDASARKAN KONDISI KLIEN

A. Mandiri

B. Kolaborasi

C. Merujuk

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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Health Ambassadors

Selasa, 09 Juni 2015

format askeb pada bayi baru lahir

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