Escolar Documentos
Profissional Documentos
Cultura Documentos
I.
PENGKAJIAN
1.1
Data Subyektif
Tanggal Pengkajian
:..........................................
Pukul
:..........................................
Tempat
:..........................................
...........................
Nama Ibu
: .........................
Umur
...........................
Umur
: .........................
Suku/ Kebangsaan
...........................
Suku/
: .........................
Kebangsaan
Agama
...........................
Agama
: .........................
Pendidikan
...........................
Pendidikan
: .........................
Pekerjaan
............................
Pekerjaan
: .........................
Penghasilan
............................
Penghasilan
: .........................
Alamat
............................
Alamat
: .........................
: ........................................jam : .................
Tempat persalinan
: ........................................
Penolong
: ........................................
Jenis Persalinan
a.
Ibu : Hipertensi/ hipotensi, partus lama, penggunaan obat, perdarahan, KPD, infeksi.
b.
Janin : Prematur/ post matur, malposisi/mal presentasi. Gawat janin. Ketuban campur
mekonium,prolaps tali pusat.
Pemeriksaan Umum
a.
Kesadaran : ................
b.
c.
d.
BB :....................kg.
e.
TB : ..........cm
f.
1.2.2
Pemeriksaan khusus
a.
Inspeksi
Kepala
: .................................................................................................................
Muka
: .................................................................................................................
Mata
: .................................................................................................................
Mulut
: .................................................................................................................
Hidung
: .................................................................................................................
Telinga
: .................................................................................................................
Leher
: .................................................................................................................
Legan tangan
: .....................................................................................................
Dada
: .................................................................................................................
Perut
: .................................................................................................................
Genetalia
: .................................................................................................................
: .....................................................................................................
: .................................................................................................................
: .................................................................................................................
: .................................................................................................................
Reflek :
Moro
: .................................................................................................................
Rotting
: .................................................................................................................
Swallowing : .................................................................................................................
Graphs
: .................................................................................................................
Sucking
: .................................................................................................................
Tonicneck : .................................................................................................................
c.
Antropometri :
PB
: ....................cm
LK
: ....................cm
LD
: ....................cm
LILA
d.
1.2.3
: ....................cm
Eliminasi
Miksi
:..........................
Mekonium
: .........................
II.
III.
Tanggal/
Data
Data
Diagnosa/ masalah
Pukul
subyektif
Obyektif
aktual
Tanggal/
Data
Data
Diagnosa/ masalah
Pukul
subyektif
Obyektif
aktual
IV.
Pukul :
..........................................
No
V.
Diagnosa
Pukul :
........................................
No
VI.
Diagnosa
Intervensi
Rasional
IMPLEMENTASI/ PELAKSANAAN
Tanggal : ...............................
Pukul :
...........................................
1.
..........................................................................................................................................
2.
..........................................................................................................................................
3.
..........................................................................................................................................
4.
..........................................................................................................................................
5.
..........................................................................................................................................
6.
Dst............
VII.
EVALUASI
Tanggal : ...............................
Pukul :
.........................................
................................................................................................................................
O
................................................................................................................................
A
................................................................................................................................
P
................................................................................................................................
http://missheni.blogspot.com/2011/01/format-askeb-bbl.html