ASUHAN KEBIDANAN PADA IBU
HAMIL
Di
……………………………………………
No.
Registrasi : ………………………………………
Tgl.
Anamnese : ………………………………………
Jam : ………………………………………
Oleh :
………………………………………
A.
DATA
SUBJEKTIF
1.
Identitas
Klien
Nama Ibu : ………………………………. Nama Suami/Penanggung Jawab : ………………………….
Umur : ………………………..…….. Umur : ………………………………………
Pendidikan
: ………………………………. Pendidikan :
………………………………………
Pekerjaan
: ………………………………. Pekerjaan :
………………………………………
Suku/Kebangsaan
: ………………………………. Suku/Kebangsaan : ………………………………………
Agama
: ………………………………. Agama :
……………………………………..
Alamat
: ………………………………. Alamat :
………………………………………
No.Telp/HP
: ………………………………. No.Telp/HP :
………………………………………
2. Kunjungan saat ini :
……………………………………………………………………………………………………
3. Keluhan Utama : ……………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
4.
Riwayat
Kehamilan Sekarang :
a. HPHT
: ……………………………………. TP :
………………………………………………………….
Umur kehamilan menurut HPHT :
…………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
5.
Riwayat
Menstruasi ;
a.
Menarche :
……………………………
b.
Siklus :
……………………………
c.
Banyaknya :
……………………………
d.
Lamanya :
……………………………
e.
Konsistensi :
……………………………
f.
Dismenorhoe :……………………………
6.
Riwayat
Kehamilan, persalinan, nifas yang lalu
|
Tgl/Thn
persalinan
|
Tempat
persalinan
|
Usia
kehamilan
|
Jenis
persalinan
|
Penolong
|
Anak
|
Meneteki
|
|||
|
Jenis
kelamin
|
BB
|
PB
|
Hidup/
meninggal
|
||||||
|
|
|
|
|
|
|
|
|
|
|
7. Riwayat Kesehatan Lalu :
…………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………...………..……………………………………………………………………………………………………………………...…………….…………………………………………………………………………………………………………………………………….
8. Riwayat Kesehatan keluarga :
……………………………………………………………………………………………...
…………………………………………………………………………………………………………………………...………..……………….………………………………………………………………………………………………………………………...……………………………………………………………………………………………………………………………...............……………………………………………………………………………………………………………………………..
9. Riwayat Keluarga Berencana :……………………………………………………………………………………………..
…………………………………………………………………………………………………………………………..…..………….………………………………………………………………………………………………………………………………
10.
Riwayat
Sosial - Ekonomi :
a. Status
Pernikahan :……………………………………………………………………………………………………….
b. Respon
Terhadap Kehamilan : ………………………………………………………………………………................
………………………………………………………………………………………………………………………............
c. Pengambilan
keputusan dalam keluarga : ……………………………………………………………………………..
………………………………………………………………………………………………………………………..……..…………………………………………………………………………………………………………………..…………..……………………………………………………………………………………………………………..………………..………………………………………………………………………………………………………..……………………..…………………………………………………………………………………………………..…………………………..……………………………………………………………………………………………..………………………………..….………………………………………………………………………………………………………………………………………………………………….
11.
Pola
Kegiatan Sehari-hari :
a.
Nutrisi
:
………………………………………………………………………………………………………………………..........
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b.
Tidur
dan istirahat :
………………………………………………………………………………………………………………………......................................................................................................................................................................................................................................................................................................................................................
c. Personal Hygiene :
………………………………………………………………………………………………………………………............
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d. Eliminasi :
1) BAB : …………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………….
2) BAK :
………………………………………………………………………………………………………………….
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e.
Seksual :
…………………………………………………………………………………………………………………
.............................................................................................................................................................................
B.
DATA
OBJEKTIF
1.
Pemeriksaan
Umum
a. Keadaan
Umum :
………………………………………………………………………………………………………..
b. Kesadaran :
………………………………………………………………………………………………………..
c. Tinggi
Badan : ………………………………………………………………………………………………………..
d. Berat
Badan Sekarang : ……………………………….….Berat
Badan Sebelumnya : ……………………………
e. Tanda-tanda
Vital : TD : .....................mmHg.
Suhu : ……………0C, Nadi : ……….x/m, RR : ……….x/m
f. Keadaan
emosional : ……………………………………………………………………………………………………….
2.
Pemeriksaan
Khusus :
a.
Kepala :
……………………………………………………………………………………………………………
………………………………………………………………………………………………………………………...
b.
Muka :
……………………………………………………………………………………………………………
………………………………………………………………………………………………………………………...
c.
Mata :
……………………………………………………………………………………………………………
………………………………………………………………………………………………………………………...
d.
Hidung :
……………………………………………………………………………………………………………
………………………………………………………………………………………………………………………...
e.
Mulut :
……………..................................................................................................................................
.....................................................................................................................................................................
f.
Telinga :
……………………………………………………………………………………………………………
………………………………………………………………………………………………………………………...
g.
Leher :
……………………………………………………………………………………………………………
………………………………………………………………………………………………………………………...
h.
Dada/Payudara : ..................................................................................................................................
………………………………………………………………………………………………………………………...
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i.
Abdomen : …………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………...
PALPASI :
Leopold
I (
menggunakan pita cm) : ………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
Leopold II :
……………………………………………………………………………………………………………………………
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Leopold III :
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Leopold IV :
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……………………………………………………………………………………………………………………………
AUSKULTASI :
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
j.
Vulva / Vagina : ……………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….
k.
Ekstremitas :
1) Atas :
……………………………………………………………………………………………………………...
………………………………………………………………………………………………………………
2) Bawah
:
…………………………………………………………………………………………………………….
………………………………………………………………………………………………………………
3.
Pemeriksaan
Penunjang :
…………………………………………………………………………………………………………………………………….
C.
ASSESMENT
1.
Diagnosa :
…………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………
Data Dasar :
…………………………………………………………………………………………………………………..
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2.
Masalah : …………………………………………………………………………………………………………………...
Data Dasar :
…………………………………………………………………………………………………………………..
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…………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………….
3.
Kebutuhan :
…………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………
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……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
4.
Diagnosa/ masalah Potensial : …………………………………………………………………………………………….
……………………………………………………………………………………………….
Dasar :
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
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5.
Tindakan Segera/ Kolaborasi : ……………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
D.
PLANNING
1.
Intervensi
:
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2.
Implementasi
:
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3.
Evaluasi
:
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Ambon, …………………………..
Mahasiswa
NIM.
Mengetahui
Pembimbing Lahan Pembimbing
Institusi
NIP. NIP.
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