Professional Documents
Culture Documents
:.............................
Nama Mahasiswa
:............................
Nomor MR
:.............................
No.Absen
:.............................
Keterampilan ke
:.............................
1. PENGKAJIAN DATA
A. Identitas/Biodata
1. Identitas Bayi
a. Nama
:..................................................
b. Umur
:..................................................
c. Tgl/Jam Lahir
:..................................................
d. Jenis kelamin
:..................................................
e. No. Status Registrasi
:..................................................
2. Identitas Orang Tua
Istri
Suami
Nama
:................................................. ...................................................
Umur
:.................................................. ...................................................
Agama
:.................................................. ...................................................
Suku/Bangsa
:.................................................. ...................................................
Pendidikan
:.................................................. ...................................................
Pekerjaan
:.................................................. ...................................................
Alamat
:...................................................... .......................................................
PENYAKIT
TM I
TM II
TM III
Kala ll
:........... jam ...........menit
4. Ketuban pecah
Spontan/amniotomi lamanya........jam, jumlahnya....... cc, warna.........., bau........
5. Komplikasi Persalinan
a. Ibu
:.....................................
b. Bayi
:.....................................
6. Keadaan Bayi
NO
1
2
3
4
5
1 5 I
5 10 II
:.................................................................
:.............................. Lamanya
:......................
:.............................. Lamanya
:......................
:.............................. No
:......................
:.............................. Lamanya
:......................
:..............................
:..............................
8. Eliminasi
a. Miksi/BAK :..........Warna : .........., Tanggal.............Selanjutnya ...... kali/hari
b. Mekonium/BAB
:............Warna
:
....................,
Tanggal...............,
selanjutnya ............kali/hari
C. PEMERIKSAAN FISIK (DATA OBYEKTIF)
1. Pemeriksaan Umum
a. KU
:..........................................................................................................
b. Suhu
:..........................................................................................................
c. Pernafasan :..........................................................................................................
d. Nadi
:..........................................................................................................
e. BB
:..........................................................................................................
f. TB
:..........................................................................................................
2. Pemeriksaan Khusus
1) Pemeriksaan Fisik
a. Kepala
:..............................................................................................
b. Muka
:..............................................................................................
c. Mata
:..............................................................................................
d. Telinga:..............................................................................................
e. Hidung
:..............................................................................................
f. Tenggorokan :..............................................................................................
g. Mulut
:..............................................................................................
h. Leher
:..............................................................................................
i. Dada
:..............................................................................................
j. Abdomen
:..............................................................................................
k. Punggung
:..............................................................................................
l. Kulit
:..............................................................................................
m. Ekstenitas
:..............................................................................................
Atas/bawah
n. Genitalis
o. Anus
:..............................................................................................
:..............................................................................................
2) Reflek
a. Reflek Moro
b. Reflek Rooting
c. Reflek Walking
d. Reflek Graphs/ Plantar
e. Refleks Sucking
f. Refleks Tonisneck
:......................................................................
:......................................................................
:......................................................................
:......................................................................
:......................................................................
:......................................................................
3) Antropomutri
a. Lingkar Kepala (LK) :..................................................................................
b. Lingkar Dada (LD) :..................................................................................
c. LILA
:..................................................................................
4) Cap Kaki
Telapak Kaki Kiri Bayi
:..................................................................................
:..................................................................................
:..................................................................................
3. Ro
Golongan Darah
:..................................................................................
Hb/SAG
:..................................................................................
:......................................................................................................................