BAB III TINJAUAN KASUS ASUHAN KEBIDANAN PADA IBU HAMIL

Hari/Tgl. Masuk Jam Tempa !e"gka#ia" $ama pe"gka#i : Kamis, 28 3 2013 : 09.00 WIB : !KM Kalapa"u"ggal : %i"a lusia"a

I.

DATA SUBJEKTIF A. IDENTITAS / BIODATA $ama )mur ,uku/Ba"gsa .gama !e"-i-ika" !eker#aa" .lama /uma+ : : : : : : : $&. ' 2* + ,u"-a Islam ,M. I/T Kp.kalapa"u"ggal / 12 /0 03 (s.ka-u"u"ggal B. ANAMNESA a. 1. 2. .lasa" Ku"#u"ga" i"i Kelu+a" u ama /i0a&a me"s ruasi 1. Hai- per ama 2. ,iklus 3. Ba"&ak"&a ,i6a -ara+ 7. 8lu9r .l1us :. (isme"9rr+9e -. : umur 13 a+u", era ur : 28 +ari, 'ama"&a : 3 +ari : 2435 ga" i pem1alu /+ari , : e"2er : i-ak a-a : i-ak a-a : Ku"#u"ga" ula"g : i1u me"gelu+ ,eri"g 1ua"g air ke2il $ama )mur ,uku/Ba"gsa .gama !e"-i-ika" !eker#aa" .lama /uma+ : : : : : : : T". ( 28 + ,u"-a Islam ,M. Wiras0as a Kp.kalapa"u"ggal / 12 /0 03 (s.ka-u"u"ggal

/i0a&a Ke+amila", !ersali"a" -a" $i6as &a"g lalu

50

I1u me"ga aka" i"i merupaka" ke+amila" &a"g per ama 1elum per"a+ mela+irka" -a" i-ak per"a+ kegugura". e. /i0a&a Ke+amila" i"i 1. Hari per ama +ai- erak+ir ;H!HT< : 12 03 2012 2. Taksira" !ersali"a" ;T!< 3. Kelu+a" kelu+a" pa-a a< 1< 2< 6. g. +. Trimes er I Trimes er II Trimes er III : Mual, pusi"g : Ti-ak a-a : ,eri"g B.K : )mur ke+amila" 1* mi"ggu : = 105/+ari : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : 09 07 2013

!ergeraka" a"ak per ama kali pergeraka" a"ak 27 #am erak+ir Kelu+a" &a"g -irasaka" 1. /asa lela+ 2. Mu" a+ -a" mual &a"g lama 3. $&eri peru 7. !a"as me"gigil :. ,aki kepala 1era *. !e"gli+a a ka1ur 3. /asa "&eri pa-a 0ak u B.K 9. !e"geluara" 2aira" per>agi"am

8. /asa ga al pa-a >ul>a, >agi"a -a" seki ar"&a: i-ak a-a 10.$&eri, kemera+a" le"ga" pa-a u"gkai 11.?e-ema i. !9la maka" -a" mi"um .. Maka"a" se+ari4+ari 8rekue"si Je"is maka"a" !9rsi #. !eru1a+a" maka" &a"g -ialami ; ermasuk "gi-am, "a6su maka" 1er am1a+ / 1erkura"g <: i-ak a-a : 35 se+ari : Me"u seim1a"g : 1 piri"g se-a"g

51

k.

Mi"um 8rekue"si Je"is mi"uma" : *48 gelas/+ari : air pu i+, e+, susu : @ukup : i-ur sia"g 2 #am, 8 #am 3. ,eksuali as 7. !eker#aa" : 15 semi"ggu, i-ak a-a kelu+a" : me"ger#aka" peker#aa" /uma+ Ta"gga seper i me"&apu, me"2u2i, -a" memasak. Ti-ak a-a peru1a+a" i-ur

l.

.k i>i as se+ari +ari 1. 2. !9la is ira+a Ti-ur malam

m. Imu"isasi TT 1. ". 9. TT I :;0:41042012< : ;0:41142012< : I1u me"ga aka" 1elum per"a+ 2. TT II /i0a&a KB

me"ggu"aka" ala k9" rasepsi apapu" /i0a&a !e"&aki ,is emik &a"g per"a+ -i-eri a 1. Ja" u"g 2. %i"#al 3. .s+ma/TB@ !aru 7. Hepa i is :. (ia1e es Meli us *. Hiper e"si 3. Apilepsi 8. 'ai" lai" p. /i0a&a pe"&aki keluarga 1. Ja" u"g 2. Hiper e"si 3. (ia1e es Meli us B. /i0a&a ,9sial : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a

52

1. Ke+amila" i"i 1< (ire"2a"aka"/ i-ak -ire"2a"aka" 2< (i erima/ i-ak -i erima 3< Je"is kelami" &a"g -i+arapka" 2. Ka0i" I )mur 20 a+u", -e"ga" suami umur 22 a+u" 'ama"&a * a+u", a"ak 4 ?ra"g r. s. . Keluarga &a"g i"ggal seruma+ : i"ggal -e"ga" suami !e"gam1il kepu usa" -a" pe"a"ggu"g #a0a1 -alam keluarga : suami Keper2a&aa" &a"g 1er+u1u"ga" -e"ga" ke+amila" : a2ara s&ukura" 7 1ula"a" -a" 3 1ula"a" /i0a&a psik9l9gi i1u er+a-ap 1. !eru1a+a" u1u+ : i1u me"erima peru1a+a" u1u+"&a saa i"i +a i. u. !ere"2a"aa" persali"a" -a" re"2a"a kega0a -arura a" 1. 2. Tempa persali"a" &a"g i1u i"gi"ka" : !uskesmas : Bi-a" : /,)(. ,ekar0a"gi !e"-ampi"g persali"a" &a"g i1u i"gi"ka": ,uami 2. !r9ses ke+amila" i"i : i1u me"erima ke+amila" i"i -e"ga" se"a"g , a us perka0i"a" : -ire"2a"aka" : -i erima : 'aki laki/perempua" sama sa#a : ,&a+

3. !e"9l9"g persali"a" &a"g i1u i"gi"ka" 7. .pa1ila er#a-i k9mplikasi, empa ru#uka" &a"g i1u i"gi"ka" :. !ersiapa" perala a" i1u -a" 1a&i ermasuk ua"g, ra"sp9r asi ser a -9"9r -ara+ #ika er#a-i kega0a -arura a"

: su-a+ -isiapka"

II. DATA OBJEKTIF

53

.. Kea-aa" umum B. Kesa-ara" @. , a us em9si9"al (. Ta"-a 4 a"-a >i al a. Teka"a" (ara+ 1. (e"&u $a-i 2. !er"a6asa" -. ,u+u A. ." r9p9me ri a. Ti"ggi 1a-a" 1. Bera 1a-a" sekara"g 2. BB se1elum +amil -. IMT e. 'I'. 8. !emeriksaa" 8isik a. Kepala -a" ram1u 1. Muka Ma a a< Kel9pak ma a 1< ,e2lera 2< K9"#u"2 i>a -< /e6leks pupil Mulu a< War"a 1i1ir 1< 'i-a+ 2< %igi -< %usi 2. 'e+er 1.

: 1aik : 29mp9sme" is : s a1il : 110/30 mmHg : 81kali/me"i : 20 kali/me"i : 3*,*C@ : 1:82m : *3kg : :3 kg : "9rmal : 2* 2m : ram1u 1ersi+, +i am -a" i-ak r9" 9k : i-ak 9e-ema, -a" i-ak a-a 2+9lasma gra>i-arum : i-ak 9e-ema : pu i+ : mera+ mu-a : p9si i6 : mera+ mu-a : 1ersi+ : i-ak a-a 2aries : i-ak a-a gi"gi>i is !em1esara" kele"#ar +&r9i: i-ak a-a

54

2. 3.

!em1esara" kele"#ar ge a+ 1e"i"g ;K%B< : i-ak a-a D! ;Jugularis De"a !ulm9"alis< : i-ak a-a pem1esara"

-. (a-a 1. !aru paru a< !alpasi a2 il >remi us 1< !erkusi 1a as paru paru 2< .uskul asi 1u"&i paru paru 2. 3. !a&u-ara I"speksi a< Be" uk 1< Ke1ersi+a" 2< !u i"g susu -< , riae !alpasi a< /asa "&eri 1< Be"#9la" 2< !e"geluara" .,I e. !u"ggu"g -a" pi"gga"g 1. 2. 6. .1-9me" I"speksi 1. Be" uk peru F

: 1e" uk -a-a sime ris : sime ris : i-ak a-a 9e-ema : 1ersi+, i-ak a-a 0+eeEi"g, r9"2+i Ja" u"g :1u"&i #a" u"g reguler

: sime ris : 1ersi+ : me"9"#9l : a-a : i-ak a-a : i-ak a-a : a-a !9sisi ula"g 1elaka"g : '9r-9sis 8isi9l9gis /asa "&eri a-a : i-ak

: mem1esar -a" mema"#a"

55

2. 3. 7. :.

!em1esara" 'uka 1ekas 9perasi , riae gra>i-arum 'i"ea "igra

: sesuai usia ke+amila" : i-ak a-a : a-a : a-a : 31 2m : (i 6u"-us era1a 1ula , lu"ak -a" i-ak : mele" i"g ;19k9"g< era1a 1 1agia" 1esar #a"i", keras, mema"#a" seper i papa" -i se1ela+ ka"a" peru i1u ; puka < -a" 1agia" 1agia" ke2il #a"i" -i se1ela+ kiri peru i1u. : Bagia" er1a0a+ era1a 1ula , keras -a" mele" i"g ;kepala<, 1agia" er1a0a+ #a"i" su-a+ i-ak 1isa -ig9&a"gka". : Bagia" er1a0a+ #a"i" a au kepala su-a+ masuk pi" u a as pa"ggul ;!.!<, p9sisi a"ga" -i>erge".

!alpasi T8) ;M2. (9"al-< 'e9p9l- I 'e9p9l- II

'e9p9l- III

'e9p9l- ID

.uskul asi a. (JJ 1. !u"2 um maksimum Ta6sira" Bera Ja"i" ;TBJ< g. Aks remi as 1. a< Be" uk 1< ?e-ema #ari #ari a"ga" 2. a< Be" uk 1< ?e-ema 2< Be is mera+/lem1ek/keras Ba0a+ : sime ris : i-ak a-a : i-ak a-a . as : sime ris : i-ak a-a : 8rekue"si 170 kali/me"i , regular : 2 #ari -i1a0a+ pusa se1ela+ ka"a" peru gram;J+9"s9"< i1u : /umus 31 4 11 5 1:: G 3100

56

-< Darises u"gkai e< /e6leks pa ella +. %e"i alia : Ti-ak -ilakuka" PEMERIKSAAN LABORATORIUM .. B. @. (. Haem9gl91i" %9l9"ga" -ara+ !r9 ei" uri"e -ilakuka" %luk9sa -ilakuka" III. ASSASMENT %2!1.0 %ra>i-a 39 mi"ggu. IV. PLANNING 1

: i-ak a-a : p9si i6 ; kiri/ka"a" <

: 11,2 grH :. : : Ti-ak Ti-ak

Me"gi"69rmasika" +asil pemeriksaa" kepa-a i1u -a" keluarga. 1a+0a kea-aa" i1u -a" #a"i" 1aik.umur ke+amila" i1u saa i"i a-ala+ 9 1ula" -e"ga" #a"i" "9rmal, -a" perkiraa" i1u mela+irka" a"ggal 09 .pril 2013. .ka" e api -ari a6sira" erse1u 1isa ma#u 2 mi"ggu a au mu"-ur 2 mi"ggu -ari 0ak u &a"g ela+ -i e" uka", i1u su-a+ me"ge a+ui +asil pemeriksaa".

Me"#elaska" pa-a i1u e" a"g ke i-ak"&ama"a" pa-a rimes er 3 &a"g mu"gki" aka" -ialami 9le+ se1agia" i1u +amil seper i seri"g B.K,-ikare"aka" ka"-u"g kemi+ &a"g er eka" 9le+ kepala 1a&i, i1u me"ger i e" a"g ke i-ak"&ama"a" &a"g mu"gki" aka" -ialami pa-a rimes er 3, seper i seri"g B.K kare"a ka"-u"g kemi+ &a"g er eka" 9le+ kepala 1a&i.

Me"ga"#urka" kepa-a i1u u" uk me"i"gka ka" asupa" "u risi -a" +i-rasi sesuai -e"ga" ke1u u+a" selama masa ke+amila", i1u mau meru1a+ p9la asupa" "u risi"&a -e"ga" me"ggu"aka" giEi seim1a"g.

57

Me"#elaska" kepa-a i1u e" a"g a"-a 1a+a&a pa-a ke+amila" misal"&a: er#a-i per-ara+a", saki kepala +e1a ,ga"ggua" pe"gli+a a",1e"gkak pa-a muka, a"ga",kaki,seluru+ u1u+,"&eri peru &a"g +e1a ,geraka" #a"i" 1erkura"g, i1u me"ger i e" a"g a"-a 1a+a&a pa-a ke+amila" -a" mampu+ me"&e1u ka" kem1ali 7 a"-a 1a+a&a ke+amila".

: *

Me"ga"#urka" i1u is ira+a 2ukup -a" i-ak 1eker#a 1era , i1u mau is ira+a &a"g 2ukup -a" i-ak aka" melakuka" peker#aa" &a"g 1era . Mem1eri a+u i1u e" a"g a ura" -a" 2ara memi"um a1le 6e 151 semasa ke+amila""&a, i1u su-a+ me"ge a+ui e" a"g a ura" -a" 2ara memi"um a1le 6e selama ke+amila""&a

me"ga"#urka" i1u u" uk mere"2a"aka" persali"a" &ai u aka" -ima"a i1u 1ersali" -a" aka" -i 9l9"g 9le+ siapa -alam pr9ses persali"a", i1u me"ge a+ui -a" mere"2a"aka" persali"a"&a -i e"aga kese+a a".

Mem1erika" k9"seli"g e" a"g a"-a4 a"-a persali"a" seper i mulas &a"g erus4me"erus -a" era ur, keluar le"-ir 1er2am1ur -ara+ -a" air4air -ari #ala" la+ir, i1u me"ger i e" a"g a"-a a"-a persali"a" -a" aka" segera me"g+u1u"gi pe ugas kese+a a" apa1ila er-apa a"-a a"-a persali"a" s1.

Me"a"&aka" pa-a i1u re"2a"a KB sela"#u "&a,i1u 1ere"2a"a u" uk me"ggu"aka" ala k9" rasepsi su" ik 3 1ula".

10 Mem1eri a+uka" i1u u" uk ku"#u"ga" ula"g 1 mi"ggu kemu-ia" &ai u pa-a a"ggal 0740742013.a au segera -a a"g apa1ila a-a kelu+a", i1u mau -a a"g u" uk memeriksaka" kem1ali ka"-u"ga""&a sesuai -e"ga" #a-0al &g ela+ -i e apka" 9le+ 1i-a".

58

ASUHAN KEBIDANAN PADA IBU BERSALIN

Hari/Tgl. Masuk Jam Tempa !e"gka#i I. DATA SUBJEKTIF A. IDENTITAS $ama )mur ,uku/Ba"gsa .gama !e"-i-ika" !eker#aa" .lama /uma+ : : : : : : : $&. ' 2* + ,u"-a Islam ,M. I/T Kp.kalapa"u"ggal / 12 /0 03 (s.ka-u"u"ggal B. ANAMNESA (DATA SUBJEKTIF) a. Kelu+a" ) ama : I1u me"gelu+ merasa mules mules se#ak -ari #am18.00 WIB, me"gaku su-a+ a-a pe"geluara" le"-ir 1er2ampur -ara+ -ari #ala" la+ir e api 1elum a-a pe"geluara" 2aira" &a"g 1a"&ak -ari #ala" la+ir. 1. Ta"-a a"-a persali"a"
59

: /a1u , 03407 42013 : 09.00 WIB : /ua"g Bersali" : %i"a lusia"ai

$ama )mur ,uku/Ba"gsa .gama !e"-i-ika" !eker#aa" .lama /uma+

: : : : : : :

T". ( 28 + ,u"-a Islam ,M. Wiras0as a Kp.kalapa"u"ggal / 12 /0 03 (s.ka-u"u"ggal

1. 2.

K9" raksi 8rekue"si 'ama"&a Kekua a"

: su-a+ a-a se#ak a"ggal 03 .pril 2013, pukul 18.00 WIB : 3 5 se iap 10 me"i : = 70 -e ik, : kua

3. 2.

Ke i-ak "&ama"a" &a"g -irasaka" : seri"g B.K !e"geluara" !er>agi"am.

1. (ara+ 'e"-ir 2. .ir Ke u1a" 3. (ara+ -. e.

: .-a : u u+ , : Ti-ak, Jumla+ : 4 Jumla+ : 4 ,War"a : 4 ,War"a : 4

Masala+4masala+ K+usus : Ti-ak a-a /i0a&a ke+amila" sekara"g 1. H!HT 2. Hai- 1ula" se1elum"&a 3. ,iklus 7. .$@ : 02403 2012 : 09407 4 2013 : 28 Hari : 95, era ur :;0:41042012< : ;0:41142012< Tempa : !KM 'ama"&a : 3 +ari

6.

/i0a&a Imu"isasi TT 1. TT I 2. TT II

g.

/i0a&a Ke+amila", persali"a" &a"g lalu : I1u me"ga aka" i"i merupaka" ke+amila" &a"g per ama 1elum per"a+ mela+irka" -a" i-ak per"a+ kegugura".

+. i.

!ergeraka" #a"i" -alam 27 #am erak+ir : = 10 5/+ari Maka" -a" mi"um erak+ir 1. Maka" erak+ir 1< Jam 2< Je"is maka"a" 3< Ba"&ak"&a 2. Mi"um erak+ir : 1*.30 WIB : "asi, sa&ur, lauk4pauk : 1 p9rsi se-a"g

60

1< Jam 2< Je"is mi"uma" 3< Ba"&ak"&a #. Alimi"asi 1< B.B erk+ir #am 2< B.K erak+ir #am k. l. m. Ti-ur erak+ir !sik9l9gis Kelu+a" lai" :4

: 13.00 WIB : air pu i+ : 1 gelas se-a"g : 03.00 WIB : 11.00 WIB

: i1u merasa 2emas me"g+a-api persali"a" : Ti-ak a-a

II. DATA OBJEKTIF .. Kea-aa" umum B. Kesa-ara" @. , a us em9si9"al (. Ta"-a 4 a"-a >i al A. ." r9p9me ri a. Teka"a" -ara+ 1. (e"&u $a-i 2. !er"a6asa" -. ,u+u 8. !emeriksaa" 8isik a. Ti"ggi 1a-a" 1. Bera 1a-a" sekara"g 2. Bera Ba-a" ,e1elum +amil -. Ke"aika" Bera 1a-a" selama +amil e. IMT ;I"-e5 Masa Tu1u+< TB ;m<2 6.Muka g. Ma a 1,:851,:8 G 21,23 /umus : BB se1elum +amil G :3 kg : Ti-ak 9e-ema 2+9lasma gra>i-arum : i-ak a-a : 1:8 2m : *3 kg : :3 kg : 12 kg : 120/80 mmHg : 81 5/me"i : 21 5/me"i : 3*, 3 C@ : Baik : 29mp9sme" is : s a1il

61

1. Kel9pak ma a 2. 3. 7. 1. 2. 3. 7. 1. 2. 3. #. (a-a 'i-a+ %igi %usi ,e2lera K9"#u"2 i>a /e6leks pupil War"a 1i1ir

: Ti-ak 9e-ema : !u i+ : Mera+ mu-a : !9si i6 : Mera+ mu-a : Bersi+ : Ti-ak a-a 2aries : Ti-ak a-a gi"ggi>i is : i-ak a-a : i-ak a-a

+. Mulu

i. 'e+er !em1esara" kele"#ar +&r9i!em1esara" kele"#ar ge a+ 1e"i"g ;K%B< JD! : i-ak a-a pem1e"gkakka" : 1e" uk -a-a sime ris/ i-ak : sime ris : i-ak a-a 9e-ema : 1ersi+ i-ak a-a 0eeEi"g -a" r9"2+i 2. Ja" u"g 3. I"speksi 1< Be" uk 2< Ke1ersi+a" 3< !u i"g susu 7< !em1esara" :< , riae palpasi 1< Be"#9la" 2< !e"geluara" : i-ak : .-a : sime ris : 1ersi+ : me"9"#9l : &a : i-ak a-a : 1u"&i #a" u"g reguler !a&u-ara : sime ris

1. !aru paru 1< !alpasi a2 il >remi us 2< !erkusi 1a as paru paru 3< .uskul asi 1u"&i paru paru

62

3< /asa "&eri i. !u"ggu"g -a" pi"gga"g 1. !9sisi ula"g 1elaka"g 2. /asa "&eri #. .1-9me" 1. I"speksi 1< Be" uk peru 2< !em1esara" 3< 'uka 1ekas 9perasi 7< , riae gra>i-arum :< 'i"ea "igra !alpasi T8) ;M2 (< : 31 2m 'e9p9l- I 'e9p9l- II

: i-ak : '9r-9sis 6isi9l9gis : i-ak a-a

: mem1esar -a" mema"#a"g : ,esuai usia ke+amila" : Ti-ak a-a : i-ak a-a : .-a

: (i 6u"-us

era1a 1ula , lu"ak -a"

i-ak

mele" i"g ;19k9"g< : Tera1a 1 1agia" 1esar, keras, mema"#a"g seper i !apa" -i se1ela+ ka"a" peru i1u ;!)K.< -a" 1agia" 1agia" ke2il #a"i" -i

'e9p9l- III

se1ela+ kiri peru i1u. : Bagia" er1a0a+ #a"i" era1a 1ula , keras -a" mele" i"g ;Kepala<, kepala su-a+ i-ak 1isa -ig9&a"gka" : Bagia" er1a0a+ #a"i" su-a+ masuk pi" u a as pa"ggul ;-i>erge"< : a-a, 6rekue"si ;3 5 -alam 10 me"i ,= 70 -e ik< kekua a" : kua , era ur : 3/:

'e9p9l- ID K9" raksi u erus !erlimaa" .uskul asi a< (JJ

!alpasi supra pu1is ka"-u"g kemi+ : k9s9"g : 8rekue"si 170 regular : 2 #ari -i 1a0a+ pusa se1ela+ ka"a" peru i1u Ta6sira" Bera Ja"i" ;TBJ<
63

1< !u"2 um maksimum

: 31 11 5 1:: G

3100gram;J+9"s9"< %. Aks remi as . as a. 1. Be" uk ?e-ema #ari #ari a"ga" : sime ris : i-ak a-a

Ba0a+ a. 1. 2. -. e. H. a. 1. 2. -. e. 6. g. a. 1. 2. -. e. 6. g. +. Be" uk ?e-ema i1ia Kemera+a" pa-a1e is Darises /e6leks pa ella ."9 4 %e"i al I"speksi Dul>a -a" >agi"a Dari2es ?e-ema !e"geluara" per>agi"am Bekas luka/luka paru ."us Haem9r9iDul>a >agi"a !9r i9 !em1ukaa" ser>iks Ke u1a" !rese" asi (e"9mi"a 9r M9ulage !e"uru"a" 1agia" ere"-a+ : i-ak a-a : i-ak a-a kelai"a" : e1al lu"ak : : 2m : ) u+ : Belaka"g kepala : ))K ka"a" -epa" : Ti-ak a-a : -i H9-ge II : Ti-ak a-a kelai"a" : i-ak a-a : i-ak a-a : i-ak a-a!eri"eum : i-ak a-a : sime ris : i-ak a-a : i-ak a-a : i-ak a-a : p9si i6

I. !emeriksaa" (alam

64

PEMERIKSAAN LABORATORIUM 1. Haem9gl91i" 2. %9l9"ga" -ara+ 3. !r9 ei" uri"e 7. %luk9sa III. ASSASEMENT %2!1.0 Hamil 70 mi"ggu, I"par u Kala I 8ase 6ase ak i6. IV. PLANNING 1. Me"&iapka" i"69rme- 29"2e" me"ge"ai i"-aka" &a"g aka" -ilakuka" selama pr9ses persali"a", ,uami i"69rme- 29"2e" . 2. Mem1eri a+uka" +asil pemeriksaa" kepa-a i1u -a" keluarga, i1u su-a+ me"ge a+ui e" a"g +asil pemeriksaa" 1a+0a kea-aa" i1u -a" #a"i" 1aik, i1u su-a+ me"ge a+ui pem1ukaa" "&a &ai u * 2m. 3. Me"ga"#urka" kepa-a i1u u" uk meme"u+i ke1u u+a" "u risi -a" +i-rasi, i1u mau memaka" sep9 9"g r9 i -a" segelas e+ ma"is 7. Me"ga"#urka" kepa-a i1u u" uk i-ak me"ge-a" se1elum pem1ukaa" le"gkap.-a" me"ga#arka" i1u e+"ik relaksasi, i1u me"ger i -a" i-ak me"ge-a". :. Mempersiapka" ala ala persali"a", ala 4ala su-a+ -ipersiapka". *. Me"g91ser>asi (JJ pa-a saa i-ak a-a k9" aksi, (JJ 1aik 1705/me"i 3. Me"-9kume" asika" +asil pemeriksaa" -i lem1ar pa 9gra6, Hasil pemeriksaa" su-a+ -i -9kume" asika". ela+ me"&e u#ui -a" me"e"ga"i : 11,2 gr H :. : Ti-ak -ilakuka" : Ti-ak -ilakuka"

65

CATATAN PERKEMBANGAN KALA II

Hari/ a"ggal Jam Tempa : /a1u , 03 4 07 4 2013 : 18.30 0i1 : !KM kalapa"u"ggal

I. DATA SUBJEKTIF I1u me"ga aka" mules"&a semaki" seri"g -a" kua ser a su-a+ keluara" 1a"&ak 2aira" -ari >agi"a, -a" klie" me"ga aka" serasa i"gi" 1ua"g air 1esar -a" erasa a-a -9r9"ga" u" uk me"era". II. DATA OBJEKTIF .. Kea-aa" )mum B. Kesa-ara" @. Kea-aa" em9si a. 1. 2. -. A. 8. : Tampak kesaki a" : 29mp9sme" is : s a1il

(. Terli+a a-a"&a a"-a -a" ge#ala Kala II &ai u : Terli+a a-a"&a -9r9"ga" &a"g kua u" uk me"era" Terli+a eka"a" a"us &a"g semaki" me"i"gka !eri"eum erli+a me"9"#9l Dul>a >agi"a -a" a"us erli+a mem1uka

Terli+a 2aira" ke u1a" -ari #ala" la+ir, 0ar"a"&a #er"i+, -a" 1a"&ak"&a I 200 22 ser a a-a pe"geluara" le"-ir -a" -ara+. !emeriksaa" Ta"-a Ta"-a Di al a. 2. Teka"a" (ara+ !er"a6asa" : 110/30 mm+g : 82 5 / me"i : 22 5 / me"i : 3*,80@ 1. $a-i -. ,u+u

%. !alpasi .1-9me"

66

T8) ;M2 (< 'e9p9l- I 'e9p9l- II

: 31 2m : (i 6u"-us era1a 1ula , lu"ak -a" i-ak mele" i"g ;19k9"g< : Tera1a 1 1agia" 1esar, keras, mema"#a"g seper i !apa" -i se1ela+ ka"a" peru i1u ;!)K.< -a" 1agia" 1agia" ke2il #a"i" -i

'e9p9l- III

se1ela+ kiri peru i1u. : Bagia" er1a0a+ #a"i" era1a 1ula , keras -a" mele" i"g ;Kepala<, kepala su-a+ i-ak 1isa -ig9&a"gka" : Bagia" er1a0a+ #a"i" su-a+ masuk pi" u a as pa"ggul ;-i>erge"< : a-a, 6rekue"si ;3 5 -alam 10 me"i ,= 70 -e ik< kekua a" : kua , era ur : 1/:

'e9p9l- ID K9" raksi u erus !erlimaa"

H. .uskul asi (JJ I. !emeriksaa" (alam a. 1. 2. -. e. 6. g. +. Dul>a/Dagi"a !9r i9 !em1ukaa" Ke u1a" !rese" asi (e"9mi"a 9r M9lase !e"uru"a" 1agia" ere"-a+ : Ti-ak .-a Kelai"a" : Ti-ak Tera1a : le"gkap ;10 2m< : su-a+ pe2a+ : Kepala : )1u" u1u" ke2il ka"a" -epa" : Ti-ak a-a : H9-ge ID : 170 5/me"i , regular.

III. ASESSMENT (A) %2!1.0 Hamil 70 mi"ggu,I"par u Kala II. IV. PLANNING (P)
67

1. Mem1eri a+uka" i1u -a" keluarga

e" a"g +ail pemeriksaa" &a"g ela+

-ilakuka" 1a+0a pem1ukaa" su-a+ le"gkap ;10 2m<, I1u -a" keluarga me"ge aui e" a"g +asil pemeriksaa" &a"g ela+ -ilakuka". 2. Me"a"&aka" kepa-a i1u siapa &a"g aka" me"ema"i i1u, I1u mau -i ema"i 9le+ suami -a" keluarga. 3. Mem1erika" -uku"ga" me" al u" uk me"gura"gi ke2emasa" a au ke aku a" i1u -e"ga" 2ara : a. 1. 2. Me"#aga pri>asi i1u. Me"#elaska" pr9ses -a" kema#ua" persali"a". Me"#elaska" pr9se-ur &a"g aka" -ilakuka" -a" ke erli1a a" i1u.

,e ela+ -i1eri pe"#elasa", i1u erli+a le1i+ e"a"g. 7. Me"ga"#urka" i1u u" uk memili+ p9sisi me"era" sesuai -e"ga" kei"gi"a" i1u e api i-ak mem1a+a&aka" i1u, &ai u -e"ga" p9sisi 1eriku : a. 1. 2. -. J9"gk9k Me"u"ggi"g Ti-ur miri"g ,e e"ga+ -u-uk

I1u memili+ p9sisi se e"ga+ -u-uk :. Me"ga#arka" i1u 2ara me"era" &a"g 1aik apa1ila a-a mules, I1u 1isa me"era" -e"ga" 1aik sesuai -e"ga" &a"g -ia#arka" 9le+ 1i-a". *. Memeriksa kem1ali kele"gkapa" par us se , pakaia" i1u -a" 1a&i"&a, semua perle"gkapa" ela+ -isiapka". 3. Memakai ala perli"-u"ga" -iri ;.!(<, .!( ela+ -ipakai. 8. Memakai saru"g a"ga" (TT pa-a a"ga" ka"a" kemu-ia" memasukka" 9ksi 9si" ke-alam spui 322 -a" mele akka" kem1ali ke par us se , saru"g a"ga" (TT ela+ -ipakai -a" 9ksi 9si" ela+ -imasuka" ke-alam par use , 9. Memimpi" i1u u" uk me"ge-a" #ika erasa mules, i1u mulai -ipimpi" me"ge-a". 10. Me"ga"#urka" i1u u" uk 1eris ira+a , maka" / mi"um #ika i-ak erasa mulas, i1u ma"ger i -a" mi"um air e+ ma"is 1 gelas. 11. Me"&iapka" kai" -ia as peru i1u -a" me"&iapka" kai" &a"g -ilipa 1/3

68

-i1agia" 1a0a+ 19k9"g i1u saa kepala 1a&i erli+a -i >ul>a :4*2m, kai" su-a+ -isimpa" -i1a0a+ 19k9"g i1u. 12. Memakai saru"g a"ga" (TT,saru"g a"ga" (TT su-a+ -i pakai 13. Mele akka" a"ga" ka"a" -i peri"eum i1u u" uk me"2ega+ r91eka" peri"eum -e"ga" -ilapisi kai" -a" a"ga" kiri melakuka" pe"eka"a" lem1u pa-a 1elaka"g kepala 1a&i u" uk me"2ega+ er#a-i -e6leksi, ke 2 a"ga" -alam p9sisi erse1u . 17. Kepala la+ir 2ek a-a"&a lili a" ali pusa -a" u"ggu kepala melakuka" pu ara" 6aksi luar,lili a" ali pusa i-ak a-a -a" kepala su-a+ melakuka" pu ara" 6aksi luar. 1:. Memp9sisika" a"ga" se2ara 1iparie al u" uk me"geluarka" 1a+u a" eri9r -a" p9s eri9r, kemu-ia" lakuka" sa"gga susur u" uk me"geluarka" 1a-a" 1a&i, 1a&i la+ir #am 19.2: 0i1, 1a&i la+ir sp9" a", #e"is kelami" laki4laki. 1*. Me"ilai seli" as -a" le aka" 1a&i -i a as peru i1u sam1il -ikeri"gka" -a" -i+a"ga ka",1a&i me"a"gis kua -a" geraka" ak i6 -a" 0ar"a kuli kemera+a". 13. memeriksa kem1ali u erus u" uk memas ika" i-ak a-a lagi 1a&i ke 2 -alam u erus, i-ak er-apa 1a&i ke 2 -alam u erus. 18. Mem1eri a+u i1u aka" -isu" ik 95& 9si",i1u se u#u u" uk -isu" ik,95& 9si" 10 I) su-a+ -isu" ika" se2ara IM -i 1/3 pa+a a as 1 me"i segera se ela+ 1a&i la+ir. 19. Melakuka" pe"#epi a" -a" pem9 9"ga" ali pusa ser a pe"gika a" ali pusa , ali pusa ela+ -i ika -e"ga" 1e"a"g ali pusa . 20. Melakuka" i"isiasi me"&usu -i"i ; IM( < -e"ga" 2ara 1a&i -ile aka" -i -a-a i1u selama I #am,IM( su-a+ -ilakuka".

69

CATATAN PERKEMBANGAN KALA III

Hari/ a"ggal J.M : /a1u, 03 4 07 4 2013 : 18.30 WIB

I. SUBJEKTIF (S) I1u me"ga aka" merasa se"a"g kare"a 1a&i"&a su-a+ la+ir -a" peru "&a masi+ erasa mules. II. OBJEKTIF (O) I"speksi .. Kea-aa" )mum : empak kelela+a" : 29mp9sme" is : s a1il B. Kesa-ara" @. Kea-aa" em9si

(. Ba&i la+ir sp9" a" +i-up, la"gsu"g me"a"gis pa-a #am 19.2: 0i1. A. Jumla+ per-ara+a" Kala II &ai u I 100 22 8. Belum erli+a a-a"&a a"-a a"-a pelepasa" plase" a %. Terli+a ali pusa -i klem -i -epa" >ul>a !alpasi .1-9me" .. T8) @. K9" raksi u erus 1aik (. Ka"-u"g kemi+ k9s9"g A. Belum erli+a a-a"&a a"-a a"-a pelepasa" plase" a seper i : 1. .-a"&a sem1ura" -ara+ se2ara i1a4 i1a. 2. Tali pusa mema"#a"g. 3. ) erus gl91uler. III. ASESSMENT (A)
70

: sepusa

B. Ti-ak era1a a-a"&a #a"i" ke 2

%2!2.0 I"par u Kala III IV. PLANNING (P) 1. Mem1eri a+u +asil pemeriksaa" 1a+0a 1a&i su-a+ la+ir, kea-aa" i1u -a" 1a&i 1aik, e api plase" a 1elum la+ir -a" segera aka" -ila+irka", I1u me"ger i 2. Melakuka" !e"ega"ga" Tali !usa Terke"-ali ;!TT< -a" -9r9"ga" -9rs9 2ra"ial pa-a saa a-a HI, -a" se ela+ erli+a a-a"&a a"-a a"-a pelepasa" plase" a &ai u : a. ) erus gl91uler 1. Tali pusa erli+a mema"#a"g 2. .-a"&a sem1ura" -ara+ se2ara i1a i1a ,e ela+ -ilakuka" !TT, -alam 0ak u : me"i plase" a la+ir sp9" a" pa-a #am 19.77 WIB. 3. Melakuka" masase 6u"-us u eri selama 1: -e ik ;1: kali masase< ,e ela+ -ilakuka" masase selama 1: -e ik, u erus i1u 1erk9" raksi -e"ga" 1aik.

71

CATATAN PERKEMBANGAN KALA IV

Hari/ a"ggal J.M : /a1u , 03 4 07 4 2013 :19.:7 WIB

I. DATA SUBJEKTIF (S) .. I1u me"ga aka" merasa lela+ persali"a""&a 1er#ala" la"2ar. B. I1u me"ga aka" masi+ merasaka" mules pa-a peru "&a II. DATA OBJEKTIF (O) I"speksi a< Kea-aa" )mum 1< Kesa-ara" 2< Kea-aa" em9si I"speksi Dul>a/Dagi"a !er-ara+a" Kala III &ai u !alpasi .1-9me" a< T8) 1< K9" raksi u erus 1aik 2< Ka"-u"g kemi+ k9s9"g III. ASESSMENT (A) !2.0 Kala ID IV. PLANNING (P) 1. Mem1eri a+u i1u +asil pemeriksaa" 1a+0a plase" a su-a+ la+ir, kea-aa" i1u 1aik, I1u me"ger i 2. Memeriksa kele"gkapa" plase" a -a" memasukka""&a ke-alam empa
72

e api merasa lega kare"a pr9ses

: ampak kelela+a" : 29mp9sme" is : s a1il

-< !lase" a la+ir sp9" a" pa-a #am 19.77 WIB : I 100 22 : 2 #ari -i1a0a+ pusa

plase" a, !lase" a le"gkap -a" -imasukka" ke-alam empa plase" a 3. Me"ge>aluasi a-a"&a laserasi peri"eum -a" #umla+ per-ara+a", i-ak a-a laserasi peri"eum, #umla+ per-ara+a" I 2: 22 7. Memas ika" u erus 1erk9" raksi -e"ga" 1aik -a" i-ak er#a-i per-ara+a" per>agi"am, ) erus 1erk9" raksi -e"ga" 1aik -a" i-ak er#a-i per-ara+a" :. Mem1iarka" 1a&i u" uk e ap melakuka" k9" ak kuli ke kuli -i -a-a i1u selama 1 #am, 1a&i masi+ melakuka" IM( *. Melakuka" pema" aua" k9" raksi u erus -a" me"2ega+ per-ara+a" per>agi"am, k9" raksi u erus 1aik 3. Me"ga#arka" i1u/keluarga 2ara melakuka" masase u erus -a" me"ilai k9" raksi, I1u 1isa melakuka" masase u erus se"-iri sesuai -e"ga" &a"g -ia#arka" 9le+ 1i-a". 8. Me"ge>aluasi #umla+ ke+ila"ga" -ara+, Jumla+ per-ara+a" Kala ID I 1004 22 9. Memeriksa kem1ali 1a&i u" uk memas ika" 1a+0a 1a&i 1er"a6as -e"ga" 1aik -a" su+u u1u+ "9rmal, 1a&i 1er"a6as "9rmal 70 5/me"i , su+u 3*,3 C@ 10. Me"empa ka" semua perala a" 1ekas pakai -alam laru a" 2+l9ri"e 0,: H u" uk -ek9" ami"asi selama 10 me"i , kemu-ia" 2u2i -a" 1ilas, pr9ses -ek9" ami"asi su-a+ -ilakuka" 11. Mem1ua"g 1a+a" 1a+a" &a"g erk9" ami"asi ke-alam empa sampa+ &a"g sesuai, 1a+a" 1a+a" &g erk9" ami"asi su-a+ -i1ua"g ke empa sampa+ &a"g sesuai. 12. Mem1ersi+ka" i1u -e"ga" me"ggu"aka" air (TT -a" mem1ersi+ka" empa i1u -e"ga" laru a" 2+l9ri"e, I1u -a" empa i1u su-a+ -i1ersi+ka" 13. Mem1erika" i1u rasa "&ama" -e"ga" me"gga" i pakaia" i1u, !akaia" i1u su-a+ -iga" i -a" i1u erli+a le1i+ "&ama" 17. Me"ga"#urka" i1u u" uk meme"u+i ke1u u+a" "u risi -a" +i-rasi, I1u maka" 1 piri"g se-a"g "asi, ika" -a" sa&ur, mi"um air pu i+ 1 gelas se-a"g. 1:. Mem1eri pil Ea 1esi, >i . 0ar"a mera+ 200.000 u"i ,a" i1i9 i2,a"alge ik

73

-a" me"#elaska" 2ara memi"um"&a &ai u pil Ea 1esi -imi"um 1 5 se+ari,>i . 2 5 -alam 27 #am,a" i1i9 i2 ; am95ili" < 3 5 se+ari-a" a"alge ik ; asam me6e"ama < 3 5 se+ari semua"&a -i mi"um -e"ga" me"ggu"aka" air pu i+,i1u 1erse-ia mi"um 91a &a"g -i1erika",-a" me"ger i a ura" pemakaia" "&a. 1*. Mele"gkapi par 9gra6, !ar 9gra6 su-a+ -ile"gkapi !ema" aua" kala ID Jam Ke Wak u Teka"a" (ara+ 20.2: 20.7: 21.00 21.1: 21.7: 22.1: 110/80 110/80 110/80 110/80 110/80 110/80 80 80 80 80 80 80 3*,3 $a-i ,u+u Ti"ggi 8u"-us ) eri 2 #r10+ps 2 #r10+ps 2 #r10+ps 2 #r10+ps 2 #r10+ps 2 #r10+ps K9" raksi ) erus Keras Keras Keras Keras Keras Keras Ka"-"g Kemi+ K9s9"g K9s9"g K9s9"g K9s9"g K9s9"g K9s9"g ,e-iki ,e-iki ,e-iki ,e-iki ,e-iki ,e-iki !er-ara+a"

1 2

3*,3

ASUHAN KEBIDANAN PADA IBU NIFAS

74

6 JAM POSTPARTUM
Hari/Tgl. Masuk Jam Tempa !e"gka#i : Kamis ,07 07 J 2013 : 01.7: WIB : /ua"g Bersali" : %i"a lusia"a

I. DATA SUBJEKTIF A. IDENTITAS/BIODATA $ama )mur ,uku/Ba"gsa .gama !e"-i-ika" !eker#aa" .lama /uma+ : : : : : : : $&. ' 2* + ,u"-a Islam ,M. I/T Kp.kalapa"u"ggal / 12 /0 03 (s.ka-u"u"ggal a. 1. Kelu+a" ) ama /i0a&a ." e"a al 1. 2. 3. 7. :. H!HT HT! )mur ke+amial" .$@ TT : 0240342012 : 0940742013 : 70 mi"ggu : 95 : 25 $ama )mur ,uku/Ba"gsa .gama !e"-i-ika" !eker#aa" .lama /uma+ : : : : : : : T". ( 28 + ,u"-a Islam ,M. Wiras0as a Kp.kalapa"u"ggal / 12 /0 03 (s.ka-u"u"ggal

: I1u me"gelu+ merasa mules pa-a peru "&a.

2. /i0a&a !ersalia"a" 1. ."ak la+ir gl/#am : 03, .pril 2013/ 19.2: WIB

75

2. 3. 7. :. *. 3. 8. 9.

Je"is Kelami"/BB/TB ./, @a2a 1a0aa" Je"is persali"a" !lase" a !eri"eum !er-ara+a" kala III !er-ara+a" kala ID

: laki4laki/3200gram/:12m : 8/9 : i-ak a-a : sp9" a" : le"gkap : u u+ : 10022 :10022 : 20022 : 1elum : su-a+ 15

10. !er-ara+a" 9 al -. /i0a&a !9s !ar um 1. 2. II. B.B B.K

DATA OBJEKTIF .. !emeriksaa" )mum a. Kea-aa" )mum 1. Kesa-ara" 2. Teka"a" -ara+ -. ,u+u e. $a-i 6. /espirasi B. a. !emeriksaa" k+usus Ma a 1. 2. 1. !a&u-ara 1. !em1esara" 2. Be" uk 3. .re9la 7. !u i"g susu :. K9lus rum : $9rmal : ,ime ris : Bersi+ : Bersi+ -a" Me"9"#9l : ,u-a+ keluara" K9"#u"g i>a ,2lera : pu i+ : Mera+ mu-a : Baik : @9mp9sme" is :110/80 mm+g : 3*,3K2 : 805/me"i : 205/me"i

76

2.

.1-9me" 1. T8) 2. K9" raksi u erus : 2 #ari -i1a0a+ pusa : Baik : /u1ra : ) u+ : Ti-ak a-a : Ti-ak a-a : Ti-ak a-a : $9rmal

-.

."9ge"i al 1. '9+ea 2. !eri"eum 3. ?e-ema 7. 'uka #a+i a" :. Darises *. !e"-ara+a"

PEMERIKSAAN LABORATORIUM 1. 2. 3. 7. III. ASSASEMENT !2.0 !9s par um * #am IV. PLANNING 1. Mem1eri a+uka" +asil pemeriksaa" kepa-a i1u -a" keluarga, i1u -a" keluarga su-a+ me"ge a+ui +asil pemeriksaa" &a"g -ilakuka". 2. Memriksa kea-aa" umum i1u,TTD, T8), ka"-u"g kemi+, k9" raksi u erus -a" per-ara+a", K) 1aik, T( 110/80 mm+g, $ 805/me"i , / 205/me"i , / 3*,3K 2, T8) 1 #ari -i 1a0a+ pusa , k9" raksi 1aik, -a" per-ara+a" I 2022. 2. !em1eria" Di .. 15, i1u me"ge a+ui -a" aka" memi"um"&a. 3. Mem1eri a+uka" i1u 1a+0a mules &a"g -irasaka" "9rmal, i1u me"ger i e" a"g pe"#elasa" 1i-a". 7. Me"ga"#urka" pa-a i1u 2ukup is ira+a -a" 2ukup "u risi -a" +i-rasi agar k9"-isi i1u le1i+ 1aik, i1u 1erse-ia er+a-ap &a"g -isara"ka". Haem9gl91i" %9l9"ga" -ara+ !r9 ei" uri"e %luk9sa : 11,2 grH :. : Ti-ak -ilakuka" : Ti-ak -ilakuka"

77

:. Me"ga"#urka" i1u u" uk melakuka" m91ilisasi -e"ga" melakuka" geraka", misal"&a #ala"4#ala" seki ar rua"ga", i1u me"ger i e" a"g pe"#elasa" &a"g -ilakuka" -a" i1u 1erse-ia melaluka" &a"g -isara"ka". *. Mem1erika" k9"seli"g .si Aklusi6 mi"imal * 1ula", i1u aka" melaksa"aka" apa &a"g -isara"ka". 3. Me"#aga ke+a"ga a" 1a&i, #ika 1a&i su-a+ B.B/B.K +arus segera -iga" i p9p9k"&a, i1u me"ger i -a" aka" melaksa"aka"&a. 8. Mem1eri a+uka" i1u e" a"g a"-a 1a+a&a pa-a 1a&i misal"&aL su+u u1u+ "aik, 1a&i ku"i"g, i1u me"ger i -a" me"ge aui. 9. Me"ga"#urka" i1u u" uk me"#emur 1a&i"&a -ipagi +ari pa-a #am 03.004 08.00 WIB u" uk me"2ega+ pe"&aki ku"i"g, i1u aka" melaksa"aka" apa &a"g -isara"ka" 10. Mem1eri a+u i1u u" uk imu"isasi 1a&i"&a 1ula" -epa", i1u aka" ku"#u"ga" pa-a 1ula" -epa". 11. Mem1eri a+u i1u u" uk segera lap9r kepe ugas apa1ila a-a a"-a 1a+a&a "i6as seper i per-ara+a" 1a"&ak, pusi"g -a" u erus lem1ek, i1u 1erse-ia lap9r apa1ila a-a a"-a4 a"-a 1a+a&a "i6as.

ASUHAN BAYI BARU LAHIR (BBL) 6 JAM

78

Hari/Tgl. Masuk Jam Tempa !e"gka#i I. I.1

: Kamis, 07 07 4 2013 : 10.2: WIB : /ua"g Bersali" : %i"a lusia"a

DATA SUBJEKTIF IDENTITAS/BIODATA $ama 1a&i )mur 1a&i Tgl/#am la+ir Je"is Kelami" Ta"ggal masuk ."ak ke $ama )mur ,uku/Ba"gsa .gama !e"-i-ika" !eker#aa" .lama /uma+ : : : : : : : : B&. ' : * #am : 03 .pril 2013, Jam 19.2: WIB : 'aki 4 laki : 2* (esem1er 2011 : 1 ; ,a u < $&. ' 2* + ,u"-a Islam ,M. I/T Kp.kalapa"u"ggal / 12 /0 03 (s.ka-u"u"ggal a. 1. 2. 3. 7. :. 1. 1. 2.
79

A. IDENTITAS BAYI

B. IDENTITAS ORANG TUA $ama )mur ,uku/Ba"gsa .gama !e"-i-ika" !eker#aa" .lama /uma+ : : : : : : : T". ) 22 + ,u"-a Islam ,M. Wiras0as a Kp.kalapa"u"ggal / 12 /0 03 (s.ka-u"u"ggal

/i0a&a pe"&aki ke+amila" !er-ara+a" !re eklampsia Aklampsia !e"&aki kelai"a" 'ai" lai" Maka"a" : Ti-ak a-a : Ti-ak a-a : Ti-ak a-a : Ti-ak a-a : Ti-ak a-a Ke1iasaa" 0ak u +amil : Maka" 3 5/+ari -e"ga" me"u giEi seim1a"g. ?1a 91a a"/#amu :

Ti-ak a-a 3. Ti-ak a-a 2. 1. 2. 3. 7. :. )mur ke+amila" Ke+amila" u"ggal/gemelli Je"is persali"a" (i 9l9"g 9le+ 'ama persali"a" 1< Kala I 2< Kala II 3< Kala III 7< Kala ID *. Ke u1a" pe2a+ 1< War"a 2< Jumla+ 3. K9mplikasi persali"a" 1< I1u 2< Ba&i 8. Kea-aa" 1a&i 1aru la+ir 1< Ba&i la"gsu"g me"a"gis/1er"a6as sp9" a" 2< %eraka" 1a&i ak i6 9. /esusi asi : i-ak -ilakuka" : &a : &a : Ti-ak a-a : Ti-ak a-a :3 :4 :4 :* : Jer"i+ : 200 22 Jam, Jam, Jam, Jam, 4 1: : 4 Me"i Me"i Me"i Me"i /i0a&a persali"a" sekara"g : 10 1ula" : u"ggal : ,p9" a" : Bi-a" 'ai" lai" :

: ,p9" a"

II. DATA OBJEKTIF .. Kea-aa" umum B. @. a. 1. 2. Kesa-ara" Ta"-a 4 a"-a >i al ,u+u !er"a6asa" Hear /a e ;H/< : 3*,3K2 : 70 5/me"i : 1705/me"i : Baik : @9mp9sme" is

80

(. a. 1. 2.

." r9p9me ri Bera 1a-a" !a"#a"g 1a-a" 'i"gkar kepala 1. @ir2um6ere" ia ,u1 ?2ipi 9 Bregma ika 2. 3. -. e. 6. @ir2um6ere" ia 8r9" 9 ?2ipi alis @ir2um6ere" ia Me" 9 ?2ipi alis : 31 2m : 30 2m : 33 2m : 33 2m :9 2m :4 : 3200 gram : :1 2m

'i"gkar -a-a 'i"gkar le"ga" a as 'i"gkar peru ;a as i"-ikasi< !emeriksaa" 8isik se2ara sis ema is Kepala 1. 2. 3. 7. :. *. Be" uk

A. a.

: : -a ar : i-ak

sime ris )1u" u1u" M9ulase a-a @apu su22e-a"eum : i-ak a-a @epal +aema 9ma : i-aka-a 'ai" lai" a-a 1. Muka 1. 1< Be" uk 2< Ta"-a a"-a i"6eksi 3< /e6lek me"ge-ip 7< /e6leks pupil :< 'ai" lai" 2. Ma a : sime ris : i-ak a-a : 1aik : 1aik : i-ak a-a Teli"ga : i-ak

81

1< Be" uk 2< Tula"g ra0a" eli"ga 3< 'e ak eli"ga se#a#ar -g" alis ma a 7< /e6leks pe"-e"gara" 3. 1< !er"a6asa" 2upi"g +i-u"g 2< War"a 1i1ir 3< /e6leks me"g+isap ;,u2ki"g< 7< /e6leks me"ela" ;,0all90i"g< :< 'a1i9skiEis -a" pala 9skiEis /e6lek /99 i"g 2. 'e+er 1. 2. -. (a-a 1. Be" uk -a-a 2. /e raksi -i"-i"g -a-a 3. 8rak ur kla>ikula 7. !aru paru .uskul asi 1< !aru paru 2< Ja" u"g :. !a&u-ara 1< Be" uk 2< !u i"g susu 3< !e"geluara" e. Ba+u, le"ga" -a" a"ga" 1. Jumla+ #ari a"ga" 2. /e6lek grapsi"g ;me"gge"ggam< 3. !eriksa kelumpu+a" pa-a le"ga" !em1e"gkaka" /e6lek T9"ik $e2k

: sime ris : keras : se#a#ar : 1aik Hi-u"g -a" Mulu : i-ak a-a : mera+ mu-a : a-a : a-a : i-ak a-a : a-a : i-ak a-a : 1aik : sime ris : i-ak a-a : i-ak a-a

: Bu"&i 1ersi+, i-ak a-a 0+eeEi"g, r9"2+i : 1u"&i ')B ()B

: sime ris : me"9"#9l : i-ak a-a : 'e"gkap : a-a

82

-a" a"ga" ;Brak+ial !als&< 7. Kelai"a" :. /e6lek M9r9 6. .1-9me" 1. 2. 3. 7. :. g. %e"i alia Ba&i laki4laki 1. 2. 3. +. !e"is 1erlu1a"g Be" uk sime ris

:Ti-ak a-a. : Ti-ak a-a :Baik : : i-ak : : i-ak a-a : i-ak a-a

!e"9"#9la" seki ar pusa ;+er"ia um1ilikus< a-a !er-ara+a" ali pusa i-ak a-a Massa pa-a a1-9me" 'ai" lai"

: &a : &a : Ti-ak a-a : sime ris : le"gkap : 1aik : 1aik : i-ak a-a : i-ak a-a : i-ak a-a : i-ak a-a : a-a : a-a : mera+ mu-a

Tes is su-a+ masuk ke-alam skr9 um Kelai"a" 1a0aa"

Tu"gkai -a" kaki 1. Be" uk 2. 3. 7. :. Jumla+ #ari kaki Ta"-a klik /e6lek Ba1i"sk& Kelai"a" Masa/ 9"#9la" ,6i"a 1i6i-a Me"i"g9kel ."us 1erlu1a"g "geluara" mek9"eum

i.

!u"ggu"g -a" a"us 1. 2. 3. 7. :.

#.

Kuli 1. War"a kuli

83

2. Der"ik kase9sa 3. 'a"ug9 7. !em1e"gkaka" :. Ta"-a la+ir PEMERIKSAAN LABORATORIUM Ti-ak -ilakuka" III. ASESSMENT $e9"a us 2ukup 1ula", umur * #am, IV. PLANNING 1. 2. 3.

: a-a : a-a : i-ak a-a : Ti-ak

Mem1ersi+ka" ma a,+i-u"g -a" mulu 1a&i -ari -ara+ -a" air ke u1a". Ma a, mulu -a" +i-u"g 1a&i ela+ -i1ersi+ka". 'e akka" 1a&i -ia as peru i1u, keri"gka" u1u+ 1a&i, Ba&i ela+ -ikeri"gka". Me"#epi ali pusa -a" mem9 9"g ali pusa -e"ga" memper a+a"ka" ke1ersi+a" pa-a saa mem9 9"g ali pusa -a" me"gika Tali pusa ela+ -iika -e"ga" ali 1e"a"g ali pusa . ali pusa ,

7. :. *. 3. 8. 9.

Me"gga" i kai" &a"g 1asa+ -a" mem1u"gkus kem1ali -e"ga" kai" &a"g +a"ga , Kai" ela+ -iga" i -e"ga" &a"g 1ersi+ -a" keri"g. Mem1erika" 1a&i pa-a i1u u" uk -isusui segera mu"gki" supa&a er#a-i k9" ak -i"i -e"ga" i1u, I1u mau me"&usui 1a&i"&a. Mem1erika" i"#eksi Di . K u" uk me"2ega+ per-ara+a" -i9 ak, Di . K ela+ -isu" ikka" pa-a 1/3 pa+a kiri. Mem1erika" salep ma a e ra sikli" 0,1H pa-a ke-ua ma a 1a&i u" uk me"2ega+ er#a-i"&a i"6eksi, ,alep ma a ela+ -i1erika". Me"gukur BB, !B, '(, 'K, 'I'. -a" periksa 6isik 1a&i, BB 3200 grm, !B :12m, '( 332m, 'K 332m, 'I'. 9 2m, ke-aa" 1a&i 1aik. Me"g91ser>asi kea-aa" umum 1a&i: per"apasa", 0ar"a kuli , ke ak i6a" se iap : me"i , ?1ser>asi ela+ -ilakuka" per"apasa"

84

705/me"i , 0ar"a kuli mera+, keak i6a" 1aik. 10. Me"ge"aka" pakaia" pa-a 1a&i, Ba&i ela+ -ike"aka" pakaia" &a"g 1ersi+ -a" keri"g. 11. Mem1erika" k9"seli"g pa-a i1u -a" keluarga 2ara e" a"g pera0a a" ali pusa &ai u ali pusa -i1ersi+ka" -e"ga" air -a" memakai sa1u" kemu-ia" keri"gka" -e"ga" kai" &a"g 1ersi+, #a"ga" memakai ramua" / 1e-ak pa-a ali pusa , I1u me"ge a+ui -a" me"ger i e" a"g 2ara pera0a a" ali pusa . 12. Mem1eri a+uka" 2iri42iri a"-a 1a+a&a &a"g +arus -i0aspa-ai pa-a 1a&i 1aru la+ir seper i per"apasa" M *05/me"i , su+u M 38K2 /N 3*K2, 1a&i erli+a ku"i"g, ali pusa keluar 2aira", 1au 1usuk / 1er-ara+, I1u me"ge a+ui e" a"g a"-a 1a+a&a pa-a 1a&i. 13. Me"&impa" 1a&i -i 195 -a" me"#aga ke+a"ga a" 1a&i -e"ga" 2ara me"#au+ka" 1a&i -ari su+u &a"g re"-a+ -a" i-ak mem1iarka" 1a&i erpapar u-ara luar, Ba&i ke+a"ga a"&a. ela+ -isimpa" -i195 -a" er#aga

85

ASUHAN KEBIDANAN PADA IBU NIFAS 8 HARI POSTPARTUM

Hari/Tgl. Masuk Jam Tempa !e"gka#i I. : /a1u,10 4 074 2013 : 08.30 WIB : !km kalapa"u"ggal : %i"a lusia"a

DATA SUBJEKTIF I1u me"ga aka" i-ak a-a kelu+a"

II. DATA OBJEKTIF .. !emeriksaa" )mum a. Kea-aa" )mum 1. Kesa-ara" 2. Teka"a" -ara+ -. ,u+u e. $a-i 6. /espirasi B. a. !emeriksaa" k+usus Ma a 1. 2. 1. 2. 'e+er .5illa K9"#u"g i>a ,2lera : !u i+ : Mera+ mu-a : Baik : @9mp9sme" is :120/80 mm+g : 3*,:K2 : 805/me"i : 205/me"i

: Ti-ak a-a pem1ekaka" kele"#ar &r9i- -a" >e"a #ugularis. : Ti-ak a-a pem1e"gkaka" kele"#ar lim6e

86

-.

!a&u-ara 1. !em1esara" 2. Be" uk 3. .re9la 7. !u i"g susu :. K9lus rum : $9rmal : ,ime ris : Bersi+ : Bersi+ -a" Me"9"#9l : ,u-a+ a-a : !er e"ga+a" ,&mpisis : Baik : ,er9sa

e.

.1-9me" 1. T8) 2. K9" raksi u erus

6.

."9ge"i al '9k+ea

C. ASSASEMENT !2.0 !9s par um 1 mi"ggu. D. PLANNING 1. 2. Mem1eri a+uka" +asil pemeriksaa" kepa-a i1u -a" keluarga, i1u -a" keluarga su-a+ me"ge a+ui +asil pemeriksaa" &a"g -il-ilakuka". Me"g91ser>asi pe"geluara" .,I, i">9lusi u eri, per-ara+a", ka"-u"g kemi+, -a" l9k+ea, semua "9rmal, asi keluar -ike-ua pa&u-ara, T8) per e"ga+a" s&m6isis, per-ara+a" "9rmal k9s9"g, l9+ea al1a. 3. 7. :. *. Mem1erika" k9"seli"g pa-a i1u e ap mem1erika" .si Asklusi6, i1u aka" e ap mem1erika" .si Asklusi6 pa-a 1a&i. Me"gi"ga ka" i1u u" uk melakuka" imu"isasi, i1u aka" me"gimu"isasi 1a&i"&a Me"ga"#urka" i1u u" uk segera -a a"g ke pe ugas kese+a a" 1ila a-a kelu+a", I1u me"ger i. Melakuka" k9" ak 0ak u u" uk ku"#u"ga" 1eriku "&a &ai u pa-a a"ggal 02 4 0: 2013, I1u mau ku"#u"ga" ula"g I 1022, ka"-u"g kemi+

87

ASUHAN BAYI BARU LAHIR (BBL) 8 HARI

Hari/Tgl. Masuk Jam Tempa !e"gka#i I. : /a1u, 10 07 4 2013 : 09.00 WIB : !km kalapa"u"ggal : %i"a lusia"a

DATA SUBJEKTIF .. I1u me"ga aka" 1a+0a i-ak a-a masala+ pa-a 1a&i"&a. B. Tali pusa su-a+ lepas pa-a +ari ke : -ari kela+ira" 1a&i. @. B.B 347 kali / +ari, B.K 849 kali/ +ari (. I1u me"ga aka" 1a+0a 1a&i me"e ek kua .

II.

DATA OBJEKTIF .. Kea-aa" umum B. Kesa-ara" @. Ta"-a4 a"-a >i al a. 1. 2. -. (. !emeriksaa" 6isik a. !a"#a"g Ba-a" : :1 2m : 3700 gram
88

: Baik. : @9mp9sme" is Hear ra e /espirasi ,u+u War"a kuli : 1385/me"i : 7* 5 / me"i : 3*,8O@ : kemera+a"

1. Bera Ba-a"

2. %eraka" -. Ta"gisa" e. 'i"gkar kepala 6. Tali pusa i-ak 1er1au III. ASSESMENT (iag"9sa

: ak i6 : kua : 33 2m : su-a+ lepas, kea-aa" pusar keri"g

: $e9"a us 2ukup 1ula" umur 8 +ari, sesuai masa ke+amila".

IV.

PENATALAKSANAAN 1. Mem1eri a+u i1u -a" keluarga e" a"g +asil pemeriksaa" 1a+0a kea-aa" 1a&i"&a -alam kea-aa" 1aik, i1u me"erima i"69rmasi -e"ga" 1aik -a" erli+a se"a"g. 2. Me"gi"ga ka" kem1ali i1u e" a"g a"-a 1a+a&a pa-a 1a&i 1aru la+ir, seper i 1a&i ku"i"g, i-ak mau me"e ek, re0el, -emam, -a" sesak "a6as, i1u me"ger i -a" -apa me"&e1u ka" 1e1erapa a"-a 1a+a&a pa-a 1a&i 1aru la+ir. 3. Me"gi"ga ka" -a" mem1eri a+uka" kem1ali e" a"g pe" i"g"&a .,I eklusi6 -a" me"ga#arka" ek"ik me"&usui &a"g 1e"ar, i1u me"ger i e" a"g pe"#elasa" &a"g -i1erika" -a" -apa me"&usui -e"ga" 1e"ar. 7. Me"-em9" rasika" kem1ali pa-a i1u 2ara mema"-ika" 1a&i, me"gga" i pakaia", me"ga" i p9p9k 1a&i, -a" me"ga"#urka" pa-a i1u #ika p9p9k 1asa+ +arus segera -iga" i, i1u me"ger i -e"ga" semua pe"#elas" &a"g -i1erika". :. Me"#elaska" pa-a i1u e" a"g pe" i"g"&a imu"isasi pa-a 1a&i, -a" me"ga"#urka" i1u u" uk mem1erika" imu"isasi le"gkap pa-a 1a&i"&a, i1u me"ger i -a" 1er#a"#i aka" mem1erika" imu"isasi le"gkap u" uk 1a&i"&a *. Me"#a-0alka" ku"#u"ga" ula"g pa-a i1u -a" 1a&i"&a &ai u se1ula" sela"#u "&a &ai u a"ggal 02 4 0: 4 2013, i1u me"ger i

89

-a" 1er#a"#i aka" k9" r9l ula"g se1ula" lagi &ai u pa-a a"ggal 02 4 0:4 2013.

ASUHAN KEBIDANAN PADA IBU NIFAS 6 MINGGU POSTPARTUM

Hari/Tgl. Masuk Jam Tempa !e"gka#i I. : /a1u,17 4 0:4 2013 : 08.00 WIB : !km kalapa"u"ggal : %i"a lusia"a

DATA SUBJEKTIF I1u me"ga aka" i-ak a-a kelu+a"

II. DATA OBJEKTIF .. !emeriksaa" )mum a. Kea-aa" )mum 1. Kesa-ara" 2. Teka"a" -ara+ -. ,u+u e. $a-i 6. /espirasi B. !emeriksaa" k+usus a. Ma a 2. K9"#u"g i>a 3. ,2lera : Mera+ mu-a : !u i+ : Baik : @9mp9sme" is :120/80 mm+g : 3*,*K2 : 805/me"i : 215/me"i

90

1. 2. -.

'e+er .5illa !a&u-ara 1. !em1esara" 2. Be" uk 3. .re9la 7. !u i"g susu :. K9lus rum

: Ti-ak a-a pem1ekaka" kele"#ar &r9i- -a" >e"a #ugularis. : Ti-ak a-a pem1e"gkaka" kele"#ar lim6e : $9rmal : ,ime ris : Bersi+ : Bersi+ -a" Me"9"#9l : ,u-a+ a-a : Ti-ak era1a : Baik : .l1a

e.

.1-9me" 1. T8) 2. K9" raksi u erus

6. a.

."9ge"i al '9k+ea

C. ASSASEMENT !2.0 !9s par um 1 mi"ggu. D. PLANNING 1. 2. Mem1eri a+uka" +asil pemeriksaa" kepa-a i1u -a" keluarga, i1u -a" keluarga su-a+ me"ge a+ui +asil pemeriksaa" &a"g -il-ilakuka". Memas ika" apaka+ i1u su-a+ me"ggu"aka" ala k9" rasepsi u" uk me"u"-a -a" me"ga ur #arak ke+amila""&a, I1u me"ga aka" su-a+ me"ggu"aka" k1 su" ik 3 1ula" -a" mulai me"ggu"aka""&a 1 mi"ggu &a"g lalu. 3. Me"ga"#urka" i1u u" uk selalu me"#aga ke1ersi+a" ala kelami""&a &ai u -e"ga" me"gga" i 2ela"a -alam mi"imal 2 kali se+ari a au apa1ila erasa lem1a1 -a" me"2u2i"&a -e"ga" air 1ersi+ se iap selesai B.K a au B.B, I1u me"ger i -a" aka" melakuka" a"#ura" &a"g -i1erika". 7. Me"gi"ga ka" i1u kem1ali u" uk melakuka" imu"isasi, i1u aka" me"gimu"isasi 1a&i"&a.

91

:.

Me"ga"#urka" i1u u" uk segera -a a"g ke pe ugas kese+a a" 1ila a-a kelu+a", I1u me"ger i

ASUHAN BAYI BARU LAHIR (BBL) 8 HARI

Hari/Tgl. Masuk Jam Tempa !e"gka#i : /a1u,30 4 07 4 2013 : 09.30 WIB : !km kalapa"u"ggal : %i"a lusia"a

II. DATA SUBJEKTIF .. I1u me"ga aka" 1a+0a i-ak a-a masala+ pa-a 1a&i"&a. B. B.B 347 kali / +ari, B.K 849 kali/ +ari @. I1u me"ga aka" 1a+0a 1a&i me"e ek kua . III. DATA OBJEKTIF .. Kea-aa" umum B. Kesa-ara" @. Ta"-a4 a"-a >i al a. 1. 2. -. (. a. Hear ra e /espirasi ,u+u War"a kuli !a"#a"g Ba-a" : 1285/me"i : 7075 / me"i : 3*,8O@ : kemera+a" !emeriksaa" 6isik : :1 2m : Baik. : @9mp9sme" is

92

1. 2. -.

Bera Ba-a" %eraka" Ta"gisa"

: 3800 gram : ak i6 : kua

IV. ASSESMENT (iag"9sa :$e9"a us 2ukup 1ula" umur 28 +ari, sesuai masa ke+amila". V. PENATALAKSANAAN 1. Mem1eri a+u i1u -a" keluarga e" a"g +asil pemeriksaa" se2ara keseluru+a" 1a+0a se2ara umum kea-aa" 1a&i 1aik, i1u -a" keluarga merasa se"a"g -e"ga" +asil pemeriksaa" erse1u . 2. Me"gi"ga ka" kem1ali i1u e" a"g a"-a 1a+a&a pa-a 1a&i 1aru la+ir, ;1a&i re0el, i-ak mau me"&usu, su+u u1u+ -i"gi"/pa"as, ali pusa 1er"a"a+/1er1au, mu" a+, -iare, ke1irua", ku"i"g, -ll<, i1u mampu me"&e1u ka" kem1ali a"-a 1a+a&a erse1u -a" i1u 1erse-ia u" uk segera me"g+u1u"gi pe ugas kese+a a" #ika a-a a"-a 1a+a&a &a"g ela+ -ise1u ka" a-i. 3. Me"gi"ga ka" i1u kem1ali 1a+0a .,I ekslusi6 merupaka" me 9-e KB alami -a" -apa -i#ala"i selama i1u 1elum me"-apa me"s ruasi se1elum * 1ula", i1u me"ger i -a" aka" me"&usuka" 1a&i"&a -e"ga" .,I eksklusi6. 7. Me"#elaska" pa-a i1u e" a"g pe" i"g"&a imu"isasi, ma2am4ma2am imu"isasi -a" #a-0al imu"isai pa-a 1a&i, i1u me"ger i -a" a+u kapa" sa#a 1a&i"&a +arus -i imu"isasi ser a aka" mem1erika" 1a&i"&a 'ima Imu"isasi -asar 'e"gkap :. Me"ga"#urka" i1u u" uk me1a0a 1a&i"&a ke p9s&a"-u/ puskesmas/ 1i-a"/ empa pele&a"a" kese+a a" lai""&a saa 1a&i 1erumur 1 1ula" u" uk me"-apa ka" imu"isasi B@% -a" !9li9 1, i1u aka" mem1a0a 1a&i ke p9s&a"-u/ puskesmas/1i-a"

93