FORMAT ASUHAN KEBIDANAN PERSALINAN NORMAL

Makalah Disusun Guna Memenuhi Tugas Dokumentasi Kebidanan

Dosen Pengampu
: Winarni, S. SiT.

Disusun Oleh

ANGKATAN TAHUN 2015

PRODI D-III KEBIDANAN

STIKES AISYIYAH SURAKARTA
2015

ASUHAN KEBIDANAN PADA IBU BERSALIN NORMAL PADA

NyDI
Tanggal masuk
Jam
Ruang
No.Register
I

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PENGUMPULA DATA
Tanggal
: ...........................................................................................
Jam
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Oleh
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A Data Subjektif
1 Identitas
Istri
Nama
Umur
Suku
Agama
Pendidikan
Penghasilan
Pekerjaan
Alamat
2

Suami

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

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Alasan Masuk
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Data Kebidanan
a Riwayat menstruasi
Menarche
Sifat darah
Siklus
Lama
Warna
Bau
Dismenorrhea
Fluor albus
HPHT
HPL

: ........... tahun
: ...........
: ........... hari
: ........... hari (teratur/tidak)
: ...........
: ...........
: ........... (sebelum/selama/sesudah)
: ........... (sedikit/banyak, gatal/tidak)
: .........................................................
: .........................................................

b Riwayat pernikahan
Status pernikahan
Usia saat menikah
Lama pernikahan

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

c Riwayat kontrasepsi
Jenis kontrasepsi
: .....................................................................
Mulai memakai
: .....................................................................
Berhenti/ganti cara : .....................................................................

Ibu

Perdarahan

Laktasi

Komplikasi

BB Lahir

Jenis
persali
nan

NIFAS

JK

Umur
Kehami
lan

Penolong

TGL LAHIR

N
o

PERSALINAN

Komplikasi

Anak

d Riwayat kehamilan, persalinan dan nifas yang lalu

Bayi

1.
2.
3.
e Riwayat kehamilan sekarang

G..P..A..
Umur kehamilan
HPHT
HPL
TM I
Keluhan
Tindakan

: ...............................................................
: ...............................................................
: ...............................................................
: ..........kali ANC,
di............................
: ...............................................................
: ...............................................................

TM II
Keluhan
Tindakan

: ..........kali ANC,
di............................
: ...............................................................
: ...............................................................

TM III
Keluhan
Tindakan

: ..........kali ANC,
di............................
: ...............................................................
: ...............................................................

Riwayat Kesehatan
a Riwayat kesehatan yang lalu

........................................................................................................
b Riwayat kesehatan sekarang

........................................................................................................
c Riwayat keturunan kembar

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d Riwayat kesehatan keluarga

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5

Pola Fungsional
a Pola Nutrisi
Kebiasaan makan/minum
Makan minum terakhir

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

b Pola Aktivitas
Aktivitas sehari-hari
Aktivitas terakhir

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

c Pola istirahat
Kebiasaan istirahat
Tidur terakhir

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

d Pola Eliminasi
Kebiasaan BAB/BAK
BAB/BAK terakhir

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

e Pola Kebersihan
Kebiasaan mandi
Mandi terakhir

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

f Pola seksual
Kebiasaan seksual
Hubungan seksual terakhir

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

6 Data psikologi, sosial budaya dan spiritual

a. Psikologi
1)

Jenis kelamin anak yang diharapkan

........................................................................................................
2)
Pengambilan keputusan dalam keluarga
........................................................................................................
3)
Konsep diri ibu
........................................................................................................
b. Social budaya
1)
2)
c.
1)
2)

Hubungan dan dukungan keluarga

........................................................................................................
Hubungan dan dukungan lingkungan sekitar
........................................................................................................
Spiritual
Pola ibadah ibu
........................................................................................................
Keyakinan ibu terhadap persalinan
........................................................................................................

B Data Objektif

Keadaan Umum

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

Kesadaran

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

Tinggi badan

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

Berat badan
Sebelum hamil
Sesudah hamil
Kenaikan BB
Lila

6
7
8
9

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

Tanda-tanda Vital
TD
: ....................................................
Pernapasan
: ....................................................
Nadi
: ....................................................
Suhu
: ....................................................
HPHT
: ....................................................
HPL
: ....................................................
UK
: ....................................................
Pemeriksaan fisik
a Kepala
: ....................................................
Rambut dan kulit kepala
: ....................................................
Muka
: ....................................................
Mata
: ....................................................
Hidung
:.....................................................
Mulut
: ....................................................
Telinga
: ....................................................
Leher
: ....................................................
b Dada
: ....................................................
Payudara
: ....................................................
c Ketiak
: ....................................................
d Abdomen
: ....................................................
Palpasi Leopold I
: ....................................................
Palpasi Leopold II
: ....................................................
Palpasi Leopold III
: ....................................................
Palpasi Leopold IV
: ....................................................
TFU
: ....................................................
TBJ
: ....................................................
Auskultasi puctum maximum : ....................................................
DJJ
: .............................................................
Frekuensi DJJ
: .............................................................
HIS
: ..........x/10 menit, durasi............
e Punggung dan pinggang

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

f Genetalia
Vulva : Oedema
Varices
Pengeluaran pervaginam
Kelenjar bartolini
Kelenjar skene

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Anus

Luka
: .........................................
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VT : tanggal.......................... Jam..........WIB Oleh : ....................

Indikasi
: ....................................................................
Tujuan
: ....................................................................
Hasil
: ....................................................................
g Ekstremitas
Atas
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Bawah : .......................................................................................
II

INTERPRETASI DATA
Tanggal
Jam

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...................................................................................................................
Dasar
S
: .....................................................................................................
O
: KU
: .................................................................
Kesadaran
: .................................................................
VS
: TD : ......................
R .........................
S
: ......................
N .........................
HPL
: .................................................................
UK
: .................................................................
Leopold I
: .................................................................
Leopold II
: .................................................................
Leopold III
: .................................................................
Leopold IV
: .................................................................
DJJ
: ......................
TFU ...................
TBJ
: ......................
HIS ......................
VT
: .................................................................
III

DIAGNOSA POTENSIAL
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IV

ANTISIPASI
..................................................................................................................

PERENCANAAN

Tanggal
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Jam
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VI

IMPLEMENTASI
Tanggal
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Jam
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VII EVALUASI
Tanggal
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Jam
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