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

...............................................................................................................
...............................................................................................................
No. Register
Masuk RS/PKM/BPM Tanggal/Pukul
Dirawat di ruang

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

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

A. Biodata
Ibu
Suami
1. Nama
: ....................................................
......................................................
2. Umur
: ....................................................
......................................................
3. Agama
: ....................................................
......................................................
4. Suku/bangsa : ....................................................
......................................................
5. Pendidikan : ....................................................
......................................................
6. Pekerjaan
: ....................................................
......................................................
7. Alamat
: ....................................................
......................................................
B. Data Subjektif
1. Alasan datang/dirawat
........................................................................................................................................
........................................................................................................................................
..
2.

Keluhan utama
........................................................................................................................................
........................................................................................................................................
..

3.

Riwayat menstruasi
Menarche : .................................
Lama
: .................................
Sifat darah : .................................

Siklus
Teratur
Keluhan

Riwayat perkawinan
Status perkawinan : .....................
Lama
: .....................

Menikah ke : ..................................
Usia menikah pertama kali : ..........

4.

5.

Riwayat obstetrik : G...... P....A....Ah....

Hamil ke
Persalinan
Tanggal

6.

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

Umur
kehamilan

Jenis
Penolong
persalinan

Nifas
Komplikasi

JK

BB lahir

Laktasi Komplikasi

Riwayat kontrasepsi yang digunakan

No

Jenis
kontrasepsi

tanggal

Pasang
oleh tempat

keluhan

tanggal

oleh

Lepas
Tempat

Alasan

7.

Riwayat Kehamilan Sekarang

a. HPM : ..........................

HPL:.......................................

b. ANC pertama umur kehamilan : .......... minggu

c. Kunjungan ANC
Trimester I
Frekuensi : ..........kali Tempat :...........................
Oleh :..................
Keluhan : .................................................................................................................
Komplikasi:................................................................................................................
Terapi
: .................................................................................................................
Trimester II
Frekuensi : ..........kali Tempat :...........................
Oleh :..................
Keluhan : .................................................................................................................
Komplikasi:................................................................................................................
Terapi
: .................................................................................................................
Trimester III
Frekuensi: ..........kali Tempat :...........................
Oleh :..................
Keluhan : .................................................................................................................
Komplikasi:................................................................................................................
Terapi
: .................................................................................................................
d. Imunisasi TT : ............kali
TT 1 : tanggal...............................
TT 2 : tanggal...............................
TT 3 : tanggal...............................
TT 4 : tanggal...............................
TT 5 : tanggal...............................
e. Pergerakan janin selama 24 jam(dalam sehari)
....................................................................................................................................
....................................................................................................................................
8.

Riwayat kesehatan
a. Penyakit yang pernah/sedang diderita (menular, menurun dan menahun)
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
b. Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan menahun)
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
c. Riwayat keturunan kembar
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
d. Riwayat operasi
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
e. Riwayat alergi obat

....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
9.

Pola pemenuhan kebutuhan

Sebelum hamil
a. Nutrisi
Makan
Frekuensi
: ........ x/hari
Jenis
: ..............................
Porsi
: ..............................
Pantangan
: ..............................
Keluhan
: ..............................
Minum
Frekuensi
: ........ x/hari
Jenis
: ..............................
Porsi
: ..............................
Pantangan
: ..............................
Keluhan
: ..............................
b. Eliminasi
BAB
Frekuensi
Warna
Konsistensi
Keluhan
BAK
Frekuensi
Warna
Konsistensi
Keluhan
c. Istirahat
Tidur siang
Lama
Keluhan
Tidur malam
Lama
Keluhan

Saat hamil
........... x/hari
................................
................................
................................
................................
........... x/hari
................................
................................
................................
................................

: ........ x/hari
: ..............................
: ..............................
: ..............................

........... x/hari
...............................
...............................
...............................

: ........ x/hari
: ..............................
: ..............................
: ..............................

........... x/hari
...............................
...............................
...............................

: ........ Jam/hari
: ................................

.................. Jam/hari
................................

: ................ Jam/hari
: ................................

............ Jam/hari
................................

d. Personal Hygiene
Mandi
: ...... x/hari
Ganti pakaian
: ...... x/hari
Gosok gigi
: ...... x/hari
Keramas
: ...... x/minggu

...... x/hari
...... x/hari
...... x/hari
...... x/minggu

e. Pola seksualitas
Frekuensi
: ...... x/minggu
Keluhan
: ................................

...... x/minggu
................................

f. Pola aktivitas (terkait kegiatan fisik, olah raga)

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

....................................................................................................................................
....................................................................................................................................
10. Kebiasaan yang mengganggu kesehatan (merokok, minum jamu, minuman
beralkohol)
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
.....
11. Data psikososial, spiritual dan ekonomi (penerimaan ibu/suami/keluarga terhadap
kelahiran, dukungan keluarga, hubungan dengan suami/keluarga/tetangga, perawatan
bayi, kegiatan ibadah, kegiatan sosial, keadaan ekonomi keluarga
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
..........
12. Pengetahuan ibu (tentang kehamilan, persalinan, nifas)
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
......
13. Lingkungan yang berpengaruh (sekitar rumah dan hewan peliharaan)
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
......
C. Data Objektif
1. Pemeriksaan umum
Keadaan umum
Kesadaran
Status emosional
Tanda vital
Tekanan darah

: .......................................................................
: .......................................................................
: .......................................................................
:
: .............mmHg
Nadi : ...........x/menit

Pernafasan
BB

2.

: ............x/menit
: ............kg

Suhu : ...........x/menit
TB
: ...........cm

Pemeriksaan Fisik
Kepala
: .................................................................................................................
Wajah
: .................................................................................................................
Mata
: .................................................................................................................
Hidung
: .................................................................................................................
Mulut
: .................................................................................................................
Telinga
: .................................................................................................................
Leher
: .................................................................................................................
Dada
: .................................................................................................................
Payudara
: .................................................................................................................
Abdomen
: .................................................................................................................
Palpasi
Leopold I

: .................................................................................................................
.................................................................................................................
Leopold II : .................................................................................................................
.................................................................................................................
Leopold III : .................................................................................................................
.................................................................................................................
Leopold IV : .................................................................................................................
.................................................................................................................
Osborn test : .................................................................................................................
Pemeriksaan Mc. Donald
TFU
: ...........cm
TBJ :..................................................................
Auskultasi
Djj
: ...........x/menit
Ekstremitas Atas
: .....................................................................................................
Ekstremitas Bawah : .....................................................................................................
Genetalia luar
: .....................................................................................................
Pemeriksaan panggul: ....................................................................................................
(bila perlu)
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
3.

Pemeriksaan penunjang
Tgl
: ....................... Pukul : .........WIB
........................................................................................................................................
........................................................................................................................................
..
........................................................................................................................................
........................................................................................................................................
..

........................................................................................................................................
........................................................................................................................................
..
4.

II.

Data penunjang
........................................................................................................................................
........................................................................................................................................
..
........................................................................................................................................
........................................................................................................................................
..
........................................................................................................................................
.

INTERPRETASI DATA
A. Diagnosa kebidanan
.....................................................................................................................................
.....................................................................................................................................
Data Dasar:
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
B. Masalah
.....................................................................................................................................
.....................................................................................................................................
Data Dasar:
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

III.

IDENTIFIKASI DAN ANTISIPASI DIAGNOSA POTENSIAL

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

IV.

TINDAKAN SEGERA
A. Mandiri
......................................................................................................................................
......................................................................................................................................
B. Kolaborasi
......................................................................................................................................
......................................................................................................................................

C. Merujuk
......................................................................................................................................
......................................................................................................................................
V.

PERENCANAAN
Tanggal : . . Pukul : .....WIB
.............................
.........
.
.
.
.
........................
.........................................................................................................................................
.............................................................................................................

VI.

PELAKSANAAN
Tanggal: .......................................... Pukul : ................WIB
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
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.............................................................................................................................................

VII. EVALUASI
Tanggal : ........................................... Pukul : .......... .....WIB
.............................................................................................................................................
.............................................................................................................................................
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Pembimbing Lapangan

Mahasiswa

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