.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
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
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Tanggal Pemberian
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BCG
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3 – 4 - 2014
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Hepatitis B
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Polio
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DPT
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Campak
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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
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
IV.
TINDAKAN SEGERA
A. Mandiri
................................................................................................................................................................................................................................................................................................
B.
Kolaborasi
................................................................................................................................................................................................................................................................................................
C.
Merujuk
................................................................................................................................................................................................................................................................................................
V.
PERENCANAAN Tanggal
: …………………. ……. Pukul : ……….....WIB
......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
VI.
PELAKSANAAN Tanggal:
..........................................
Pukul : ................WIB
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
VII.
EVALUASI Tanggal
: ...........................................
Pukul : .......... .....WIB
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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