ASUHAN
KEBIDANAN PADA IBU DENGAN ......
DI................
Pengkajian
data Tanggal ……………………….jam ………oleh...........
No Register
:
I.
PENGKAJIAN
DATA
Data Subjektif
Biodata Istri Suami
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1
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Nama
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2
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Umur
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3
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Agama
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4
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Suku/bangsa
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5
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Pendidikan
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6
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Pekerjaan
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7
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Alamat
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8
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No.Telp
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1.
Keluhan Utama:
………………………………………………………………………………………………………………………….
2.
Riwayat Perkawinan
Kawin : … kali.
Usia Saat Nikah : … tahun.
Usia Pernikahan : … tahun.
3.
Riwayat Haid
Menarche : … tahun.
Siklus : … hari.
Lamanya : … hari.
Banyaknya : … cc.
4.
Riwayat Obstetri:
………………………………………………………………………………………………………………………….
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Hamil ke-
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Persalinan
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Nifas
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|||||||
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Lahir
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Umur khamilan
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Jns prsalinan
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penolong
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komplikasi
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JK
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BB Lahir
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Laktasi
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Komplikasi
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5.
Riwayat KB
.............................................................................................
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No.
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Jns Kontrasepsi
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Pasang
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Lepas
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||||||
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Tgl
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Oleh
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Tempat
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Keluhan
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Tgl.
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Oleh
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Tempat
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Alasan
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6. Riwayat Ginekologi
- Perdarahan diwaktu haid.............
- Perdarahaan diluar haid.............
- Riwayat keputihan...................
- Riwayat perdarahan setalah berhubungan............
- Riwayat adanya tumor payudara dan alat kelamin..........
- Riwayat nyeri panggul...................
- Riwayat kelainan alat geneital..............
- Keluhan menopouse.....................
7.
Riwayat Kesehatan Ibu
.............................................................................................
8.
Riwayat Kesehatan Keluarga
.............................................................................................
9.
Pola Kehidupan Sehari-hari
·
Nutrisi :
- Eliminasi :
- Istirahat :
- Aktivitas :
- Personal Higiene :
- Seksual :
10. Data
Psikososial/Spiritual
.............................................................................................
.............................................................................................
Data Objektif:
1.
Pemeriksaan Fisik
- Keadaan umum : Kesadaran:
- Status emosional :
- Tanda vital
Tekanan darah :
Nadi :
Pernafasan :
Suhu :
- BB/TB :
- Kepala dan leher
Bentuk kepala :
Mata :
Leher :
- Dada :
- Payudara
Bentuk :
Bekas operasi :
Puting susu :
- Abdomen
Bentuk :
- Tangan dan kaki
Oedem :
Varices :
Reflek patella :
- Genetalia luar
Bekas luka :
Kelenjar bartholini :
Pengeluaran :
- Anus
- Ekstrimitas :
2.
Pemeriksaan bimanual :
3.
Pemeriksaan Inspekulo :
.............................................................................................
4.
Data Penunjang
Pemeriksaan
darah, tanggal …………………..
Hasil:
………………………………………………………
Pemeriksaan
urine, tanggal ……………………
Hasil:
………………………………………………………
Pemeriksaan PAP
Smear tanggal, hasil
Pemeriksaan penunjang lain: USG,
Foto thorax, mammografi dll
Catatan Medik lain…………….
II. INTERPRETASI DATA
a. Diagnosa
kebidanan
........................................................................................................................................................................................................................
Data
Dasar:
........................................................................................................................................................................................................................
b. Masalah
..................................................................................................................................................................................................................................
Data Dasar:
..................................................................................................................................................................................................................................
Kebutuhan
........................................................................................................................................................................................................................
Data
Dasar:
........................................................................................................................................................................................................................
III.
IDENTIFIKASI
DIAGNOSA/MASALAH POTENSIAL DAN ANTISIPASI PENANGANAN
a. Diagnosa
Potensial
........................................................................................................................................................................................................................
Data
Dasar:
..................................................................................................................................................................................................................................
Masalah Potensial
..................................................................................................................................................................................................................................
Data
Dasar:
..................................................................................................................................................................................................................................
Antisipasi
..................................................................................................................................................................................................................................
IV.
MENETAPKAN
KEBUTUHAN TERHADAP TINDAKAN SEGERA BERDASARKAN KONDISI KLIEN
a.
Mandiri
........................................................................................................................................................................................................................
b.
Kolaborasi
..................................................................................................................................................................................................................................
c.
Merujuk
..................................................................................................................................................................................................................................
V.
RENCANA TINDAKAN, tanggal
............................jam .......
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VI. IMPLEMENTASI /PELAKSANAANTanggal
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VII. EVALUASI Tanggal
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