FORMAT ASKEB PADA IBU HAMIL

ASUHAN KEBIDANAN PADA IBU HAMIL

NO. REGISTER                                 : ……………………………………………………..

MASUK RS TANGGAL, JAM         : ……………………………………………………...

DIRAWAT DI RUANG                    : ...................................................................................

I.              PENGKAJIAN DATA, Oleh:..........................................Tanggal/Jam: .......................

A.    Biodata                    Ibu                                        Suami

1.       Nama              : ..........................................    .................................................

2.       Umur              : ..........................................    .................................................

3.       Agama            : ..........................................    .................................................

4.       Suku/bangsa   : ..........................................    .................................................

5.       Pendidikan     : ..........................................    .................................................

6.       Pekerjaan        : ..........................................    .................................................

7.       Alamat           : ..........................................    .................................................

B.     Data Subjektif

1.       Alasan kunjungan saat ini

................................................................................................................................................................................................................................................................

2.       Riwayat kehamilan ini

a.       Riwayat menstruasi

HPM ................................................... HPL ............................................

Menarche umur ............. tahun, siklus .............. hari, lama ............ hari,

Banyaknya ..................... cc, warna ..............keluhan .............

b.       Tanda-tanda kehamilan

....................................................................................................................................................................................................................................

c.       Pergerakan janin yang pertama pada umur kehamilan ..............minggu, pergerakan janin da,lam 24 jam terakhir .................. kali

d.      Keluhan yang dirasakan

..................................................................................................................................................................................................................................................

....................................................................................................

3.       Pola Pemenuhan Kebutuhan Sehari-hari

a.       Pola nutrisi                       Makan                                     Minum

Frekuensi             ...........................................     .....................................

Macam                 ...........................................     .....................................

Jumlah                  ...........................................     .....................................

Keluhan               ...........................................     .....................................

Pantangan            ...........................................     .....................................

b.       Pola eliminasi                   BAB                                        BAK

Frekuensi             ...........................................     .....................................

Warna                  ...........................................     .....................................

Bau                      ...........................................     .....................................

Konsistensi          ...........................................     .....................................

Jumlah                  ...........................................     ......................................

c.       Pola aktivitas

Kegiatan sehari-hari         : .......................................................................

Istirahat/tidur                   : .......................................................................

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

Seksualitas                       : Frekuensi ......................................................

                                           Keluhan ........................................................

d.      Imunisasi

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

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

4.       Riwayat kehamilan, persalinan dan nifas yang lalu

Hamil ke	Persalinan							Nifas
	Tgl lahir	Umur kehamilan	Jenis persalinan	penolong	Komplikasi	Jenis kelamin	BB lahir	laktasi	komplikasi

5.       Riwayat kontrasepsi yang digunakan

No	Jenis kontrasepsi	Pasang				Lepas
		tanggal	Oleh	tempat	keluhan	tanggal	oleh	tempat	alasan

6.       Riwayat kesehatan

a.       Penyakit yang pernah/sedang diderita

....................................................................................................................................................................................................................................

b.       Penyakit yang pernah/sedang diderita keluarga

....................................................................................................................................................................................................................................

c.       Riwayat keturunan kembar

....................................................................................................................................................................................................................................

d.      Kebiasaan-kebiasaan

Merokok ..................................................................................................

Minum jamu-jamuan ...............................................................................

Minum-minuman keras ...........................................................................

Makanan/minuman pantang ....................................................................

C.     Data Objektif

1.       Pemeriksaan Fisik

a.       Keadaan umum .............................. kesadaran ........................................

b.       Tanda vital

Tekanan darah     : ...................................................................................

Nadi                     : ...................................................................................

Pernafasan           : ...................................................................................

Suhu                     : ...................................................................................

c.       BB/TB/LLA        : ...................................................................................

d.      Kepala dan leher 

Oedem wajah       : ...................................................................................

Cloasma gravidarum  + / -

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

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

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

e.       Payudara

Bentuk                 : ...................................................................................

Puting susu          : ...................................................................................

Colostrum            : ...................................................................................

f.        Abdomen

Bentuk                 : ...................................................................................

Bekas luka           : ...................................................................................

Strie gravidarum  : ...................................................................................

Palpasi Leopold  

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

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

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

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

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

TBJ                      : ...................................................................................

Auskultasi DJJ     : Punctum maksimum .................................................

  Frekuensi: .................kali per menit (.... / .... / ....)

g.       Tangan dan kaki

Oedem                 : ...................................................................................

Varices                 : ...................................................................................

Reflek patela        : ...................................................................................

Kuku                    : ...................................................................................

h.       Genetalia luar      

Tanda chadwich  : ...................................................................................

Varices                 : ...................................................................................

Bekas luka           : ...................................................................................

Kelenjar bartholini: .................................................................................

Pengeluaran         : ...................................................................................

i.         Anus       

Hemoroid             : ...................................................................................

2.       Pemeriksaan Panggul Luar (bila perlu)

Distansia Spinarum    : ............... cm

Distansia Cristarum    : ................ cm

Distansia Boudelogue: ................ cm

Ukuran Lingkar panggul:.............cm

3.       Pemeriksaan Panggul Dalam (bila perlu)

.........................................................................................................................

.........................................................................................................................

4.       Pemeriksaan Penunjang

a.       Pemeriksaan Laboratorium

Darah, tanggal:               

Hasil ........................................................................................................

....................................................................................................................................................................................................................................

Urine, tanggal:

Hasil ........................................................................................................

....................................................................................................................................................................................................................................

b.       Pemeriksaan Radiologi

USG/foto rontgent/NST/amniosintesis, tanggal:

Hasil ........................................................................................................

....................................................................................................................................................................................................................................

c.       Catatan Medik lain

..................................................................................................................

..................................................................................................................

II.           INTERPRETASI DATA

A.    Diagnosa kebidanan

..............................................................................................................................................................................................................................................................

Data Dasar:

............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

B.     Masalah

..............................................................................................................................................................................................................................................................

Data Dasar:

............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

C.     Kebutuhan

..............................................................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................................

III.        IDENTIFIKASI DIAGNOSA/MASALAH POTENSIAL DAN ANTISIPASI PENANGANAN

A.    Diagnosa Potensial

..............................................................................................................................................................................................................................................................

B.     Masalah Potensial

..............................................................................................................................................................................................................................................................

............................................................................................................................................................................................................................................................................

C.     Antisipasi

..................................................................................................................................................................................................................................................................................................................................................................................................................

IV.        MENETAPKAN KEBUTUHAN TERHADAP TINDAKAN SEGERA BERDASARKAN KONDISI KLIEN

A.    Mandiri

..............................................................................................................................................................................................................................................................

B.     Kolaborasi

..............................................................................................................................................................................................................................................................

C.     Merujuk

..............................................................................................................................................................................................................................................................

V.           RENCANA ASUHAN YANG MENYELURUH, tanggal ............................jam .......

a.              ...............................................................................................................................

b.             ................................................................................................................................

c.              ................................................................................................................................

d.             ................................................................................................................................

VI.        IMPLEMENTASI Tanggal ............................... jam ..........                                                    

a.              ..................................................................................................................................

b.             ..................................................................................................................................

c.              ..................................................................................................................................

d.             ...................................................................................................................................

VII.     EVALUASI Tanggal ............................... jam ..........  

a.              ....................................................................................................................................

b.             ....................................................................................................................................

c.              ...................................................................................................................................

d.             ....................................................................................................................................