ASUHAN KEBIDANAN PADA IBU HAMIL

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No. Register: ....................................

Masuk RS/PKM/BPM Tanggal/Pukul: .............

Dirawat di ruang: .............................................................................

PENGKAJIAN DATA, Tanggal/Pukul : ............................... Oleh : ...................................Biodata Ibu SuamiNama: .................................................... ......................................................Umur: .................................................... ......................................................Agama: .................................................... ......................................................Suku/bangsa: .................................................... ......................................................Pendidikan: .................................................... ......................................................Pekerjaan: .................................................... ......................................................Alamat: .................................................... ......................................................

Data SubjektifAlasan datang/dirawat

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Keluhan utama

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Riwayat menstruasi

Menarche: .................................Siklus: ........................................

Lama: .................................Teratur: ........................................

Sifat darah: .................................Keluhan: ........................................

Riwayat perkawinan

Status perkawinan: .....................Menikah ke: ..................................

Lama: .....................Usia menikah pertama kali: ..........

Riwayat obstetrik : G...... P....A....Ah....

Hamil ke

Persalinan

Nifas

Tanggal

Umur kehamilan

Jenis persalinan

Penolong

Komplikasi

JK

BB lahir

Laktasi

Komplikasi

Riwayat kontrasepsi yang digunakan

No

Jenis kontrasepsi

Pasang

Lepas

tanggal

oleh

tempat

keluhan

tanggal

oleh

Tempat

Alasan

Riwayat Kehamilan Sekarang

a.HPM : ..........................HPL:.......................................

b.ANC pertama umur kehamilan: .......... minggu

c.Kunjungan ANC

Trimester I

Frekuensi: ..........kaliTempat :...........................Oleh :..................

Keluhan: .................................................................................................................

Komplikasi:................................................................................................................

Terapi: .................................................................................................................

Trimester II

Frekuensi: ..........kaliTempat :...........................Oleh :..................

Keluhan: .................................................................................................................

Komplikasi:................................................................................................................

Terapi: .................................................................................................................

Trimester III

Frekuensi: ..........kaliTempat :...........................Oleh :..................

Keluhan: .................................................................................................................

Komplikasi:................................................................................................................

Terapi: .................................................................................................................

d.Imunisasi TT : ............kali

TT 1 : tanggal...............................

TT 2 : tanggal...............................

TT 3 : tanggal...............................

TT 4 : tanggal...............................

TT 5 : tanggal...............................

e.Pergerakan janin selama 24 jam(dalam sehari)

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Riwayat kesehatanPenyakit yang pernah/sedang diderita (menular, menurun dan menahun)

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Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan menahun)

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Riwayat keturunan kembar

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Riwayat operasi

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Riwayat alergi obat

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Pola pemenuhan kebutuhan

Sebelum hamilSaat hamil

Nutrisi

Makan

Frekuensi: ........ x/hari........... x/hari

Jenis: ..............................................................

Porsi: ..............................................................

Pantangan: ..............................................................

Keluhan: ..............................................................

Minum

Frekuensi: ........ x/hari........... x/hari

Jenis: ..............................................................

Porsi: ..............................................................

Pantangan: ..............................................................

Keluhan: ..............................................................

Eliminasi

BAB

Frekuensi: ........ x/hari........... x/hari

Warna: .............................................................

Konsistensi: .............................................................

Keluhan: .............................................................

BAK

Frekuensi: ........ x/hari........... x/hari

Warna: .............................................................

Konsistensi: .............................................................

Keluhan: .............................................................

Istirahat

Tidur siang

Lama: ........ Jam/hari.................. Jam/hari

Keluhan: ................................................................

Tidur malam

Lama: ................ Jam/hari............ Jam/hari

Keluhan: ................................................................

Personal Hygiene

Mandi: ...... x/hari...... x/hari

Ganti pakaian: ...... x/hari...... x/hari

Gosok gigi: ...... x/hari...... x/hari

Keramas: ...... x/minggu...... x/minggu

Pola seksualitas

Frekuensi: ...... x/minggu...... x/minggu

Keluhan: ................................................................

Pola aktivitas (terkait kegiatan fisik, olah raga)

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Kebiasaan yang mengganggu kesehatan (merokok, minum jamu, minuman beralkohol)

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Data psikososial, spiritual dan ekonomi (penerimaan ibu/suami/keluarga terhadap kelahiran, dukungan keluarga, hubungan dengan suami/keluarga/tetangga, perawatan bayi, kegiatan ibadah, kegiatan sosial, keadaan ekonomi keluarga

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Pengetahuan ibu (tentang kehamilan, persalinan, nifas)

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Lingkungan yang berpengaruh (sekitar rumah dan hewan peliharaan)

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Data ObjektifPemeriksaan umum

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

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

Status emosional: .......................................................................

Tanda vital:

Tekanan darah: .............mmHgNadi: ...........x/menit

Pernafasan: ............x/menitSuhu: ...........x/menit

BB: ............kgTB: ...........cm

Pemeriksaan Fisik

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

Wajah: .................................................................................................................

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

Hidung: .................................................................................................................

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

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

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

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

Payudara: .................................................................................................................

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

Palpasi

Leopold I: .................................................................................................................

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Leopold II: .................................................................................................................

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Leopold III: .................................................................................................................

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Leopold IV: .................................................................................................................

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Osborn test: .................................................................................................................

Pemeriksaan Mc. Donald

TFU: ...........cm TBJ:..................................................................

Auskultasi

Djj: ...........x/menit

Ekstremitas Atas: .....................................................................................................

Ekstremitas Bawah: .....................................................................................................

Genetalia luar: .....................................................................................................

Pemeriksaan panggul: ....................................................................................................

(bila perlu) .....................................................................................................

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Pemeriksaan penunjangTgl: ....................... Pukul: .........WIB

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Data penunjang

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INTERPRETASI DATADiagnosa kebidanan

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Data Dasar:

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Masalah

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Data Dasar:

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IDENTIFIKASI DAN ANTISIPASI DIAGNOSA POTENSIAL

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TINDAKAN SEGERAMandiri

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Kolaborasi

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Merujuk

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PERENCANAANTanggal : . . Pukul : .....WIB

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PELAKSANAANTanggal: .......................................... Pukul : ................WIB

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EVALUASITanggal : ........................................... Pukul : ...............WIB

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Pembimbing Lapangan

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Mahasiswa

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Pembimbing Institusi

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