ASUHAN KEBIDANAN 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.
....................................................................................................................................
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