Format Asuhan Bayi, Balita Dan Anak Pra Sekolah 5r5m1h
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IK-POLTEKKES-SMG-01010-03-UPM-08
Lampiran 6. Format Laporan Bayi, Balita dan Anak Pra Sekolah LAPORAN ASUHAN KEBIDANAN PADA BAYI / BALITA / ANAK PRASEKOLAH
A. PENGKAJIAN Tanggal
:..................................
Waktu
:..................................
Tempat
:..................................
B. IDENTITAS a. Identitas Bayi Nama
:..............................
Tgl/Jam lahir
:..............................
Jenis kelamin
:..............................
b. Identitas Orang tua Nama ibu
: .............................
Nama Suami
: .........................
Umur
...............................
Umur
: .........................
Agama
:..............................
Agama
: .........................
Pendidikan
: .............................
Pendidikan
: .........................
Pekerjaan
: .............................
Pekerjaan
: .........................
Alamat
: .............................
Alamat
: ..........................
C. DATA SUBYEKTIF 1.
Alasan Datang : ................................................................................................................................... ...................................................................................................................................
`
Keluhan Utama : ................................................................................................................................... ................................................................................................................................... 2. Riwayat Kesehatan: Dahulu : ................................................................................................................................... Sekarang : ................................................................................................................................... ...................................................................................................................................
Modul Praktik Semester V Prodi DIV Kebidanan
IK-POLTEKKES-SMG-01010-03-UPM-08
Keluarga : ................................................................................................................................... 3. Riwayat kehamilan, persalinan dan nifas: Dahulu : ................................................................................................................................... ................................................................................................................................... Sekarang : ................................................................................................................................... ................................................................................................................................... 4. Riwayat tumbang Pertumbuhan BB
:……...................................……………………...............
Perkembangan anak
:..........................................................................................
Kelainan bawaan
:..........................................................................................
5. Riwayat Imunisasi
:.....................................................................................
6. Pola kebiasaan sehari- hari: Pola nutrisi
:.......................................................................................................
................................................................................................................................... Pola eliminasi :....................................................................................................... ................................................................................................................................... Pola istirahat
:.......................................................................................................
................................................................................................................................... Pola aktifitas
:.......................................................................................................
................................................................................................................................... Personal hygiene :.................................................................................................... ................................................................................................................................... 7. Pola Sosial Ekonomi
:..........................................................................................
D. DATA OBYEKTIF 1. Pemeriksaan Umum Keadaan umum :......................................... Kesadaran
:..........................................
Vital signs
: N =................x/mnt RR = ..................x/mnt T = ..................0C
Modul Praktik Semester V Prodi DIV Kebidanan
IK-POLTEKKES-SMG-01010-03-UPM-08
2. Pengukuran antropometri: BB
:................kg
Lingkar kepala/ LK
:................cm
PB
:................cm
LILA
:................cm
3. Status Present: Kepala
:...............................
Muka
:...............................
Mata
:...............................
Hidung
:................................
Mulut
:.............................
Telinga
:...............................
Leher
:.............................
Dada
:............................
Pulmo/COR
:.............................
Abdomen
:................................
Genetalia
:...............................
Punggung
:..............................
Anus
:..................................
Ekstremitas
:...........................
Kulit
:................................
E. ANALISA …...................................................................................................…………………… ……………………........................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................
F. PENATALAKSANAAN Tanggal...........................…. Jam…...........… 1. ...................................................................................................................................... Hasil : .......................................................................................................................... 2. ...................................................................................................................................... Hasil : .......................................................................................................................... 3. ......................................................................................................................................
Modul Praktik Semester V Prodi DIV Kebidanan
IK-POLTEKKES-SMG-01010-03-UPM-08
Hasil : .......................................................................................................................... 4. ...................................................................................................................................... Hasil : .......................................................................................................................... 5. ...................................................................................................................................... Hasil :........................................................................................................................... 6. ...................................................................................................................................... Hasil :........................................................................................................................... 7. ...................................................................................................................................... Hasil :........................................................................................................................... 8. ...................................................................................................................................... Hasil :...........................................................................................................................
9. ...................................................................................................................................... Hasil :........................................................................................................................... 10. ...................................................................................................................................... Hasil :........................................................................................................................... ........................, ....................................2017 Pembimbing Klinik
Praktikan
______________________
_____________________ Mengetahui
Pembimbing Institusi
___________________________
Modul Praktik Semester V Prodi DIV Kebidanan
Lampiran 6. Format Laporan Bayi, Balita dan Anak Pra Sekolah LAPORAN ASUHAN KEBIDANAN PADA BAYI / BALITA / ANAK PRASEKOLAH
A. PENGKAJIAN Tanggal
:..................................
Waktu
:..................................
Tempat
:..................................
B. IDENTITAS a. Identitas Bayi Nama
:..............................
Tgl/Jam lahir
:..............................
Jenis kelamin
:..............................
b. Identitas Orang tua Nama ibu
: .............................
Nama Suami
: .........................
Umur
...............................
Umur
: .........................
Agama
:..............................
Agama
: .........................
Pendidikan
: .............................
Pendidikan
: .........................
Pekerjaan
: .............................
Pekerjaan
: .........................
Alamat
: .............................
Alamat
: ..........................
C. DATA SUBYEKTIF 1.
Alasan Datang : ................................................................................................................................... ...................................................................................................................................
`
Keluhan Utama : ................................................................................................................................... ................................................................................................................................... 2. Riwayat Kesehatan: Dahulu : ................................................................................................................................... Sekarang : ................................................................................................................................... ...................................................................................................................................
Modul Praktik Semester V Prodi DIV Kebidanan
IK-POLTEKKES-SMG-01010-03-UPM-08
Keluarga : ................................................................................................................................... 3. Riwayat kehamilan, persalinan dan nifas: Dahulu : ................................................................................................................................... ................................................................................................................................... Sekarang : ................................................................................................................................... ................................................................................................................................... 4. Riwayat tumbang Pertumbuhan BB
:……...................................……………………...............
Perkembangan anak
:..........................................................................................
Kelainan bawaan
:..........................................................................................
5. Riwayat Imunisasi
:.....................................................................................
6. Pola kebiasaan sehari- hari: Pola nutrisi
:.......................................................................................................
................................................................................................................................... Pola eliminasi :....................................................................................................... ................................................................................................................................... Pola istirahat
:.......................................................................................................
................................................................................................................................... Pola aktifitas
:.......................................................................................................
................................................................................................................................... Personal hygiene :.................................................................................................... ................................................................................................................................... 7. Pola Sosial Ekonomi
:..........................................................................................
D. DATA OBYEKTIF 1. Pemeriksaan Umum Keadaan umum :......................................... Kesadaran
:..........................................
Vital signs
: N =................x/mnt RR = ..................x/mnt T = ..................0C
Modul Praktik Semester V Prodi DIV Kebidanan
IK-POLTEKKES-SMG-01010-03-UPM-08
2. Pengukuran antropometri: BB
:................kg
Lingkar kepala/ LK
:................cm
PB
:................cm
LILA
:................cm
3. Status Present: Kepala
:...............................
Muka
:...............................
Mata
:...............................
Hidung
:................................
Mulut
:.............................
Telinga
:...............................
Leher
:.............................
Dada
:............................
Pulmo/COR
:.............................
Abdomen
:................................
Genetalia
:...............................
Punggung
:..............................
Anus
:..................................
Ekstremitas
:...........................
Kulit
:................................
E. ANALISA …...................................................................................................…………………… ……………………........................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................
F. PENATALAKSANAAN Tanggal...........................…. Jam…...........… 1. ...................................................................................................................................... Hasil : .......................................................................................................................... 2. ...................................................................................................................................... Hasil : .......................................................................................................................... 3. ......................................................................................................................................
Modul Praktik Semester V Prodi DIV Kebidanan
IK-POLTEKKES-SMG-01010-03-UPM-08
Hasil : .......................................................................................................................... 4. ...................................................................................................................................... Hasil : .......................................................................................................................... 5. ...................................................................................................................................... Hasil :........................................................................................................................... 6. ...................................................................................................................................... Hasil :........................................................................................................................... 7. ...................................................................................................................................... Hasil :........................................................................................................................... 8. ...................................................................................................................................... Hasil :...........................................................................................................................
9. ...................................................................................................................................... Hasil :........................................................................................................................... 10. ...................................................................................................................................... Hasil :........................................................................................................................... ........................, ....................................2017 Pembimbing Klinik
Praktikan
______________________
_____________________ Mengetahui
Pembimbing Institusi
___________________________
Modul Praktik Semester V Prodi DIV Kebidanan
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