KEMENTERIAN KESEHATAN R.I.

POLITEKNIK KESEHATAN
PALANGKA RAYA
Jl.G.Obos No.30 32 Palangka Raya.Tlp/Fax : (0536)
21768,35146,37504
E-mail : poltekkes_kalteng@telkom.net
NAMA MAHASISWA
NIM
TEMPAT PRAKTEK
TANGGAL PRAKTEK

: DIAN NOVIYANTI
: PO.62.24.2.11.121
: ...............................................
: ...............................................

FORMAT PENGKAJIAN ASUHAN PADA IBU BERSALIN

Hari/Tanggal
Pukul

I. PENGKAJIAN DATA
A. BIODATA
Nama Ibu
: .......................................
Umur
: .......................................
Suku/Bangsa : .......................................
Agama
: .......................................
Pendidikan
: .......................................
Pekerjaan
: .......................................
Alamat Rumah : .......................................
Telepon
: .......................................

Nama Suami
Umur
Suku/Bangsa
Agama
Pendidikan
Pekerjaan
Alamat Rumah
Telepon

: ........................
: ........................

:...............................
:...
:...
:...
:...
:...
:...
:...

B. ANAMNESA (DATA SUBYEKTIF)

Pada Tanggal.........................
Pukul :..
1). Alasan kunjungan / keluhan Utama : ........................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
2). HPHT : ............................................
3). TP
: ............................................
4). Tanda tanda Persalinan
Kontraksi : ............................... Sejak tanggal :.. Pukul :..
Frekuensi : ............................... Kali,setiap
:...................... menit.
Lamanya : ............................... Kekuatan
:
Lokasi ketidaknyamanan: ..........................................................................
5). Pengeluaran Pervaginam
Darah + Lendir : [ ] ada
[ ] Tidak
Air ketuban
: [ ] ada
[ ] Tidak
jumlah :cc
Warna........................................
Darah
: [ ] ada
[ ] Tidak
jumlah :.cc
Warna.......................................
6).Riwayat Kehamilan, persalinan dan nifas terdahulu
Hamil
Tgl/Thn
BBL
Usia
Jenis
penolong
Jenis
penyulit
ke
Persalinan
kehamilan persalinan
kelamin

7). Riwayat Kesehatan

Penyakit yang pernah atau sedang diderita

Penyakit
Klien
Jantung
Hipertensi
Hepar
Diabetes Melitus
PMS
Campak
Malaria
TBC
Lainnya

Keluarga

Keturunan Kembar dari pihak ibu/bapak :

Ada/Tidak Ada
8). Riwayat Kebiasaan
a. Pola Nutrisi
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
....................................................................................................................................................
b. Pola Istirahat
Istirahat Malam :.................................................................................................................
Istirahat Siang

:.................................................................................................................

c. Aktifitas Sehari-hari
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
d. Personal Hygiene
Mandi
: .........................................................................................................
Keramas
: .........................................................................................................
Ganti celana dalam : .........................................................................................................
Kebersihan kuku
: .........................................................................................................
e. Seksualitas
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
f. Riwayat Imunisasi TT
:
[ ] dapat
berapa kali :x
Tanggal :I..... II
[ ] tidak dapat
g. Riwayat KB
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................

II.PEMERIKSAAN FISIK

1. PEMERIKSAAN UMUM
a.Keadaan Umum
: .....................................................................................
b.Kesadaran
: .....................................................................................
c. Tanda-tanda Vital
TD
: ..........................mmHg
Nadi
: .......................x/ menit
Respirasi : .......................x/ menit
Suhu
: .......................oC
d.BB sekarang
: .................kg
e.BB sebelum hamil : .................kg
f.TB
: ................cm
g.LILA
: ................cm
2. PEMERIKSAAN HEAD TO TOE
1) Kepala dan Rambut
Warna
: [ ] hitam
[ ] lain-lain (sebutkan)
Distribusi
: [ ] merata
[ ] tidak merata
[ ] lebat
[ ] tidak lebat
Kebersihan
: [ ] bersih
[ ] tidak bersih
Kekuatan
: [ ] kuat
[ ] mudah rontok/tercabut
Keadaan kulit kepala
: [ ] sehat
[ ] ada infeksi
[ ] berketombe
2) Muka
Oedema
: [ ] ada
[ ] tidak ada
Chloasmagravidarum
: [ ]ada
[ ] tidak ada
3) Mata
Konjungtiva
: [ ] merah
[ ] merah muda
[ ] pucat
Sclera
: [ ] ikterik
[ ] putih
Kemampuan penglihatan
: [ ] baik
[ ] kabur
[ ] tidak dapat melihat
4) Mulut
Gigi
: [ ] lengkap [ ] tidak lengkap/berlubang
[ ] karies
[ ] bersih
[ ] bernoda
Mukosa Bibir
: [ ] lembab [ ] kering
Gangguan bau mulut
: [ ] ya
[ ] tidak
5) Telinga
Keadaan Telinga
: [ ] bersih
[ ] kotor
Pengeluaran telinga
: [ ] ada (sebutkan).
[ ] tidak ada
Kemampuan pendengaran
: [ ] baik
[ ] kurang baik
[ ] tidak dapat mendengar
6) Hidung
Keadaan hidung
: [ ] bersih
[ ] tidak ada
Kemampuan penciuman
: [ ] baik
[ ] kurang baik
Terlihat pernafasan cuping hidung
: [ ] ya
[ ] tidak
7) Leher
Bentuk
: [ ] simetris [ ] tidak simetris
Pembesaran kelenjar tiroid
: [ ] ada
[ ] tidak ada
Pembesaran vena jugularis
: [ ] ada
[ ] tidak ada
Pembesaran KGB/Limfe
: [ ] ada
[ ] tidak ada
8)

9)

Dada
Bentuk
Retraksi dada
Payudara

: [ ] simetris
: [ ] ada

[ ] tidak simetris
[ ] tidak ada

Kesimetrisan
Hiperpegmintasi Aerola
Keadaan putting susu
Pengeluaran
Teraba benjolan
Denyut jantung
10) Abdomen
Pembesaran
Warna / hiperpegmintasi
Bekas luka oprasi
Linea
Striae
Leopold I
Leopold II
Leopold III
Leopold IV
Kontraksi

1. Intensitas
2. Lama
3. Frekuensi

:[
:[
:[
:[
:[
:[

] simetris
] ada
] menonjol keluar
] ASI
] Ya
] teratur

[
[
[
[
[
[

] tidak simetris
] tidak ada
] tenggelam kedalam
] lainnya..
] tidak teraba
] tidak teratur

: .....................................................................
: .....................................................................
: [
[ ] tidak ada
: .....................................................................
: .....................................................................
: .....................................................................
: .....................................................................
: .....................................................................
: .....................................................................
: .....................................................................
: .....................................................................
: .....................................................................
: .....................................................................
: .....................................................................
: .....................................................................

TBBJ
DJJ
Supra pubik
11) Genetalia
Vulva/vagina : a. Oedema
: .....................................................................
b. Varises
: .....................................................................
c. Luka
: .....................................................................
d. Pengeluaran : .....................................................................
e. Nyeri
: .....................................................................
f. Kemerahan : .....................................................................
12) Perineum
Bekas luka parut
: .....................................................................
Menonjol
:......................................................................
Varises
: .....................................................................
13) Ekstremitas
Tangan
: kuku
: [ ] bersih
[ ] kotor
Oedema
: [ ] ada
[ ] tidak ada
Kaki
:varises
: [ ] ada
[ ] tidak ada
Oedema
: [ ] ada
[ ] tidak ada
Nyeri tekan
: [ ] ya
[ ] tidak
Refleks Patella
:......................................................................
14. Pemeriksaan Bimanual ( PD )
Vulva / vagina : Oedema
: [ ] ya
[ ] tidak
Pengeluaran
:
Serviks
: Pendataran
: [ ] ya
[ ] tidak, bila tidak arah
Pembukaan
: [ ] utuh
[ ] pecah
Selaput ketuban
: [ ] utuh
[ ] pecah
[ ] menonjol [ ] tidak
Bagian Terendah
: [ ] kepala
[ ] bokong

Penurunan
Posisi
Tali Pusat

: ...............................................................................................
: ...............................................................................................
: [ ] teraba
[ ] tidak teraba

ada

III.

PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium
Tanggal ................................................................
Darah
: Hb
:
Golongan darah
:
Rhesus
:
Urine
: protein urine
:
Reduksi
:
2. Pemeriksaan Penunjang Lainnya
......................................................................................................................................
......................................................................................................................................
3. Pemeriksaan Kemajuan Persalinan
a. Kala I
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
b. Kala II
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
c. Kala III
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
d. Kala IV
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
e. Jumlah Perdarahan
...............................................................................................................................
...............................................................................................................................
Palangka Raya ,
Mahasiswa

Pembimbing Lahan

(
NIP.

(DIAN NOVIYANTI)
NIM.PO.62.24.2.11.121

)
Mengetahui,
Pembimbing Institusi

( LEGAWATI, S.SiT,M.PH )
NIP. 19800301 200212 2 003

201