CONTOH FORMAT ASKEB PADA BAYI BALITA

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No. Register                            : ………………………….

Masuk RS tanggal / jam          : ………………………….

Dirawat diruang                      : ………………………….

I.    PENGKAJIAN   Tanggal : ...................., Jam : ...............WIB, Oleh : ...........................…......

A.  DATA SUBJEKTIF

1.                  Biodata

a.                Identitas Bayi/Balita

Nama                           : ...................................................      

Umur                           : ...................................................                  

Jenis kelamin               : ...................................................

b.                Identitas Orang Tua

                                                Ibu                                                       Ayah

Nama                           : ...................................................       ................................................

Umur                           : ...................................................       ................................................

Agama                         : ...................................................       ................................................

Suku/Bangsa               : ...................................................       ................................................

Pendidikan                  : ...................................................       ................................................

Pekerjaan                     : ...................................................       ................................................

Alamat                         : ...................................................       ................................................

No. Telp                      : ...................................................       ................................................

2.                  Alasan Masuk/ Kunjungan

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3.                   Keluhan Utama

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4.                  Riwayat Antenatal

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

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

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

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

e.    Keluhan                              : ..............................................................................................

f.     Penyakit selama hamil        : ..............................................................................................

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g.    Kebiasaan                           : ..............................................................................................

(makan, minum obat/jamu)  ..............................................................................................

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h.    Komplikasi                        

·      Ibu                                 : ..............................................................................................

·      Janin                               : ..............................................................................................

                

5.                  Riwayat Intranatal

a.    Lahir tanggal          : ...............................               jam      : .................... WIB

b.   Usia gestasi             : .................. minggu

c.    Jenis persalinan       : ..............................................................................................................

d.   Penolong/tempat     : ..............................................................................................................

e.    Komplikasi                        

·      Ibu                     : ..............................................................................................................

·      Janin                   : ..............................................................................................................

6.     Riwayat Kesehatan

a.    Penyakit yang pernah/sedang diderita (menular, menurun dan menahun)

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b.    Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan menahun)

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c.    Riwayat rawat inap & operasi

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d.   Riwayat alergi makanan/obat

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7.    Riwayat Imunisasi

Jenis	Tanggal Pemberian
BCG	3 – 4 - 2014
Hepatitis B
Polio
DPT
Campak

8.    Pola Pemenuhan Kebutuhan Sehari-hari

a.    Nutrisi

Makan                                                                  Minum

Frekuensi              : .............................                 Frekuensi         : .............................

Jenis                     : .............................                 Jenis                : .............................

Porsi                     : .............................                 Porsi                : .............................

Pantangan                        : .............................                 Pantangan       : .............................

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

b.    Eliminasi

BAB                                                                     BAK

Frekuensi              : .............................                 Frekuensi         : .............................

Warna                   : .............................                 Warna              : .............................

Konsistensi           : .............................                 Konsistensi      : .............................

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

c.    Istirahat

Tidur siang                                                           Tidur malam

Lama                    : .............................                 Lama               : .............................

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

B.                         DATA OBYEKTIF

1. Pemeriksaan umum

Keadaan Umum          : ....................................                     

Tanda-Tanda Vital      : S : ...........⁰c               N : .......... x/menit       R : .......... x/menit

PB                               : ................cm             BB : ............... gram

2.  Pemeriksaan fisik

a.                 Kepala                              

            Bentuk                         : ..............................................................................................................

            Rambut                        : ..............................................................................................................

            Muka                           : ..............................................................................................................

            Mata                            : ..............................................................................................................

            Hidung                        : ..............................................................................................................

            Mulut                          : ..............................................................................................................

            Telinga                        : ..............................................................................................................

Lingkar kepala             : ......... cm

b.                Leher                                 : ..............................................................................................................

c.                Dada                          

            Bentuk                                    : ..............................................................................................................

            Puting                          : ..............................................................................................................

            Gerakan                       : ..............................................................................................................

            Payudara                     : ..............................................................................................................

            Paru-Paru                    : ..............................................................................................................

            Jantung                        : ..............................................................................................................

            Lingkar dada               : ............ cm

d.               Abdomen                   

Bentuk                         : ..............................................................................................................

Dinding Perut              : ..............................................................................................................

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

            Palpasi                         : ..............................................................................................................

            Perkusi                        : ..............................................................................................................

            Auskultasi                   : ..............................................................................................................

e.    Ekstremitas atas          : .................................................................................. LILA : ..........cm

f.     Ekstremitas bawah       : ..............................................................................................................

g.    Genetalia                    

Laki-Laki                    : ..............................................................................................................

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Perempuan                  : ..............................................................................................................

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h.    Anus                            : ..............................................................................................................

Mekonium                   : ..............................................................................................................

i.      Punggung                    : ..............................................................................................................

j.                  Kulit                            : ..............................................................................................................

3.  Pemeriksaan khusus

Personal sosial      : ..........................................................................................................................

Motorik halus       :  .........................................................................................................................

Motorik kasar       :  .........................................................................................................................

Bahasa                  :  .........................................................................................................................

           

II.      INTERPRETASI DATA

A.    Diagnosa kebidanan

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Data Dasar:

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B.     Masalah

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Data Dasar:

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III.        IDENTIFIKASI DAN ANTISIPASI DIAGNOSA POTENSIAL

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IV.        TINDAKAN SEGERA

A.       Mandiri

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B.        Kolaborasi

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C.        Merujuk

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V.           PERENCANAAN       Tanggal : …………………. …….     Pukul : ……….....WIB

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VI.        PELAKSANAAN        Tanggal: ..........................................   Pukul : ................WIB

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VII.     EVALUASI                 Tanggal : ........................................... Pukul : .......... .....WIB

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