ASUHAN KEBIDANAN PADA BALITA SEHAT

AN....... USIA.....

DI....................................

PENGKAJIAN

Tanggal : ...................................................................................................

Waktu : ...................................................................................................

Tempat : ...................................................................................................

IDENTITAS

a. Identitas Bayi

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

Tanggal/jam lahir : .......................................................................................

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

b. Identitas Orang Tua

Nama : ................................... Nama suami : ... .............................

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

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

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

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

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

I. DATA SUBJEKTIF

1. ALASAN DATANG

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2. KELUHAN UTAMA

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3. RIWAYAT KESEHATAN IBU DAN KELUARGA

a. Sekarang :

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b. Dahulu :

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c. Keluarga :

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4. RIWAYAT KESEHATAN ANAK

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5. RIWAYAT KEHAMILAN, PERSALINAN DAN NIFAS

Umur ibu saat hamil : ...................................................

G..... P..... A.....

Usia kehamilan : ...................................................

ANC saat hamil : ...................................................

Imunisasi yang didapat saat hamil : ...................................................

Obat- obatan yang didapat saat hamil : ...................................................

Tanggal persalinan : ...................................................

Proses persalinan : ...................................................

Penolong : ...................................................

Antropometri saat lahir :

BB : ........ gr PB : ........ cm LK :........ cm LD : ........ cm

6. RIWAYAT IMUNISASI

Vaksin Diberikan tanggal Diberikan umur Keterangan

BCG

DPT

Polio

Campak

Hepatitis B
7. PERTUMBUHAN DAN PEKEMBANGAN

a. Motorik

Mengguling, umur : ...............................................................

Duduk, umur : ...............................................................

Merangkak, umur : ...............................................................

Berdiri, umur : ...............................................................

Berjalan, umur : ...............................................................

b. Sosial kognitif

Tersenyum, umur : ...................................................

Mengucap kata pertama, umur : ...................................................

Bermain, umur : ...................................................

Sekolah, umur : ...................................................

c. Bahasa

...............................................................................................................

8. FREKUENSI PEMERIKSAAN KESEHATAN : ......... x

9. POLA PEMENUHAN KEBUTUHAN SEHARI-HARI

a. Pola Nutrisi :

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...............................................................................................................

...............................................................................................................

b. Pola Eliminasi :

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 c. Pola Istirahat :

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..............................................................................................................

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d. Pola Hygiene :

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10. DATA EKONOMI, SOSIAL, BUDAYA

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11. TINGKAT PENGETAHUAN IBU

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II. DATA OBJEKTIF

1. PEMERIKSAAN FISIK

a. Pemeriksaan Umum

Keadaan umum : ...............................................................

Kesadaran : ...............................................................

Vital sign :

Nadi : ...............................................................

Suhu : ...............................................................
 RR : ...............................................................

b. Pengekuran Antropometri

BB : ...................................................................................................

PB : ...................................................................................................

LK : ...................................................................................................

LD : ...................................................................................................

LILA : ...................................................................................................

c. Keadaan Bayi

Menangis : .......................................................................................

Warna kulit : .......................................................................................

Turgor : .......................................................................................

2. STATUS PRESENT

Kepala : .......................................................................................

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

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

Hitung : .......................................................................................

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

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

Leher : .......................................................................................

Dada : .......................................................................................

Ketiak : .......................................................................................

Pulmo/con : .......................................................................................

Abdomen : .......................................................................................

Genetalia : .......................................................................................

Punggung : .......................................................................................

Anus : .......................................................................................
 Ekstremitas : .......................................................................................

: .......................................................................................

Kulit : .......................................................................................

3. PEMERIKSAAN PENUNJANG :

a. Laboratorium :

Hb : .......................................................................................

Urine protein : .......................................................................................

Urine reduksi : .......................................................................................

b. Pemeriksaan lain : USG/ SCAN : ...............................................................

c. DDST : .......................................................................................

d. Pemantauan buku KIA : ...........................................................................

III. ASSESMENT

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IV. PELAKSANAAN
Tanggal : .............................................................. Jam : .......................

1. ......................................................................................................................

Hasil : ...........................................................................................................

2. ......................................................................................................................

Hasil : ...........................................................................................................

3. ......................................................................................................................

Hasil : ...........................................................................................................

4. ......................................................................................................................

Hasil : ...........................................................................................................
5. ......................................................................................................................

Hasil : ...........................................................................................................

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