Sabtu, 13 Februari 2016

CONTOH FORMAT ASKEB PADA BAYI BALITA

By Unknown di Februari 13, 2016
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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
      ...............................................................................................................................................
            ................................................................................................................................................
3.                   Keluhan Utama
            ................................................................................................................................................
            ................................................................................................................................................
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        : ..............................................................................................
                                              ..............................................................................................
g.    Kebiasaan                           : ..............................................................................................
(makan, minum obat/jamu)  ..............................................................................................
                                              ..............................................................................................
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)
..........................................................................................................................................................................................................................................................................................
b.    Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan menahun)
..........................................................................................................................................................................................................................................................................................
c.    Riwayat rawat inap & operasi
..........................................................................................................................................................................................................................................................................................
d.   Riwayat alergi makanan/obat
..........................................................................................................................................................................................................................................................................................

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                    : ..............................................................................................................
                                      ..............................................................................................................
Perempuan                  : ..............................................................................................................
                                      ..............................................................................................................
h.    Anus                            : ..............................................................................................................
Mekonium                   : ..............................................................................................................
i.      Punggung                    : ..............................................................................................................
j.                  Kulit                            : ..............................................................................................................

3.  Pemeriksaan khusus
Personal sosial      : ..........................................................................................................................
Motorik halus       :  .........................................................................................................................
Motorik kasar       :  .........................................................................................................................
Bahasa                  :  .........................................................................................................................



           
II.      INTERPRETASI DATA
A.    Diagnosa kebidanan
............................................................................................................................................................................................................................................................................................
Data Dasar:
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................................................................................................................................................................................................................

B.     Masalah
............................................................................................................................................................................................................................................................................................
Data Dasar:
......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

III.        IDENTIFIKASI DAN ANTISIPASI DIAGNOSA POTENSIAL
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IV.        TINDAKAN SEGERA
A.       Mandiri
................................................................................................................................................................................................................................................................................................
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
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

VII.     EVALUASI                 Tanggal : ........................................... Pukul : .......... .....WIB
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Pembimbing Institusi



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Pembimbing Lapangan



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Mahasiswa



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