ASKEB KB

ASUHAN KEBIDANAN PADA AKSEPTOR

ALAT KONTRASEPSI...................

            No. Register :

Tanggal / jam :

Tempat           :

I.                   PENGAKAJIAN DATA

DATA SUBYEKTIF

IDENTITAS                          Istri                                          Suami

Nama               :          

Umur               :          

Agama             :

Suku/Bangsa   :          

Pendidikan      :          

Pekerjaan         :          

Alamat                        :          

                                   

No. telp.          :          

1. Alasan kunjungan : .......................menstruasi bulan ini........., dukungan suami untuk menggunakan alat kontrasepsi.....

2.  Riwayat Menstruasi :HPHT.... , Menarche….  tahun, Siklus…..hari, Banyaknya…  , Lama..... hari, Keluhan........

3.  Riwayat Pernikahan : Ibu menikah umur....tahun, pernikahan ke...., dengan usia pernikahan....tahun.

4.  Riwayat Obstetri : G....P.. A.. Ah..

      Anak Pertama : jenis kelamin.... , persalinan.... , penolong..... , komplikasi....., Lahir....

5.      Riwayat Kontrasepsi : bila lebih dari 1 jenis menggunakan matrik

No.	Jns Kontrasepsi	Pasang/mulai menggunakan				Lepas/Berhenti menggunakan
		Tgl	Oleh	Tempat	Keluhan	Tgl.	Oleh	Tempat	Alasan

6.      Riwayat Kesehatan:

7.   Pola pemenuhan kebutuhan sehari-hari :

·         Pola Nutrisi : Makan....., minum..........

·         Pola Eliminasi : BAB …, BAK…….

·         Personal Hygiene :

·         Pola Aktivitas

a.       Kegiatan sehari-hari :

b.      Istirahat dan tidur : 

c.       Seksualitas :

8.   Riwayat Psikososial Spiritual :

DATA OBYEKTIF

1.      Pemeriksaan Umum

a. Keadaan umum          :

            Kesadaran                   :

         b. Tanda vital

             Tekanan darah         : ....... mmHg

             Nadi                                    : ......x /menit

             Suhu                        : ....... ^oC

             Pernapasan              : .......x /menit

         c. Antropometri : TB/BB/LILA : ...... cm/ ..... kg/ .....cm.

2.   Pemeriksaan fisik ( Inspeksi, Palpasi, Auskultasi, Perkusi )

a. Kepala dan leher        :

b. Muka/ wajah              :

c. Dada/ payudara          :

d. Abdomen                   :

e. Alat kelamin               :

f. Ekstremitas                 :

g. khususnya untuk calon akseptor IUD perlu pemeriksaan inspeculo  :

3.   Data Penunjang

a. Pemeriksaan Laboratorium :

b. Pemeriksaan penunjang yang lain :

I.              INTERPRETASI DATA

A.    Diagnosa kebidanan

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Data Dasar:

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B.     Masalah

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Data Dasar:

.............................................................................................................................................................................................................................................................. Kebutuhan

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Data Dasar:

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II.           IDENTIFIKASI DIAGNOSA/MASALAH POTENSIAL DAN ANTISIPASI PENANGANAN

A.    Diagnosa Potensial

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Data Dasar:

.............................................................................................................................................................................................................................................................. Masalah Potensial

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Data Dasar:

.............................................................................................................................................................................................................................................................. Antisipasi

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III.        MENETAPKAN KEBUTUHAN TERHADAP TINDAKAN SEGERA BERDASARKAN KONDISI KLIEN

A.    Mandiri

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B.     Kolaborasi

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C.     Merujuk

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IV.        RENCANA TINDAKAN, tanggal ............................jam .......

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V.           IMPLEMENTASI /PELAKSANAANTanggal ............................... jam ..........                                                

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VI.        EVALUASI Tanggal ............................... jam ..........  

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