Nama ..................................

POLTEKKES KEMENKES YOGYAKARTA Keterampilan ke..................

JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================
ASUHAN KEBIDANAN PADA GANGGUAN SISTEM REPRODUKSI

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Masuk RS Tgl, Jam
Dirawat di Ruang
Biodata
Nama
:
Umur
:
Pendidikan
:
Pekerjaan
:
Agama
:
Suku/ Bangsa
:
Alamat
:

:
:
:
Ibu
.......................................................
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.......................................................
.......................................................
.......................................................
.......................................................

Suami
.......................................................
.......................................................
.......................................................
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.......................................................
.......................................................

DATA SUBJEKTIF (Tanggal.. Jam..WIB)

1. Kunjungan saat ini
Kunjungan Pertama
Kunjungan Ulang
Keluhan Utama

.
2. Riwayat Perkawinan
Kawin . kali, Kawin pertama umur tahun . Dengan suami sekarang
tahun .
3. Riwayat Menstruasi
Menarche umur . Tahun. Siklus . hari. Teratur/tidak. Lama hari .
Sifat darah : encer/beku. Bau .. Fluor albus ya/tidak . Dismenorroe ya/tidak .
Banyaknya cc. HPM ..
4. Riwayat kehamilan, persalinan dan nifas yang lalu
P. Ab Ah
Ha
mil
Tgl lahir
ke

Persalinan
Umur
kehamilan

Jenis Persalinan Penolong

Nifas
Komplikasi
Ibu
Bayi

JK BB Lahir

Laktasi

Komplikasi

5. Riwayat kontrasepsi yang digunakan

No Jenis
Mulai Memakai
Berhenti/Ganti cara
Kontrasepsi Tanggal Oleh Tempat Keluhan Tanggal Oleh Tempat Alasan

POLTEKKES KEMENKES YOGYAKARTA

JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================
6. Riwayat kesehatan
a. Penyakit sistemik yang pernah/sedang diderita
................................................................................................................................................
................................................................................................................................................
b. Penyakit yang pernah/sedang diderita keluarga
................................................................................................................................................
................................................................................................................................................
c. Riwayat penyakit ginekologi
................................................................................................................................................
................................................................................................................................................
7. Pola Pemenuhan Kebutuhan Sehari hari
a. Pola Nutrisi
Makan
Minum
Frekuensi
................................................. .................................................
Macam
................................................. ............................................
.....
Jumlah
................................................. .................................................
Keluhan
................................................. .................................................
b. Pola Eliminasi
BAB
BAK
Frekuensi
................................................. .................................................
Warna
................................................. .................................................
Bau
................................................. .................................................
Konsisten
................................................. .................................................
Jumlah
................................................. .................................................
c. Pola aktivitas
Kegiatan sehari-hari : ....................................................................................................
Istirahat/Tidur
: ....................................................................................................
Seksualitas
:Frekuensi .....................................Keluhan.................................
d. Personal Hygiene
Kebiasaan mandi ........ kali/hari
Kebiasaan membersihkan alat kelamin ...........................................................................
Kebiasaan mengganti pakaian dalam ..............................................................................
Jenis pakaian dalam yang digunakan ..............................................................................
8. Keadaan Psiko Sosial Spiritual
a. Pengetahuan ibu tentang alat kontrasepsi

b. Pengetahuan ibu tentang alat kontrasepsi yang dipakai sekarang

c. Dukungan suami/keluarga

POLTEKKES KEMENKES YOGYAKARTA

JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================
DATA OBJEKTIF (Tanggal.. Jam..WIB)
1. Pemeriksaan Fisik
a. Keadaan umum...................................
Kesadaran......................................
b. Tanda Vital
Tekanan darah
: ...........mmHg
Nadi
: ...........kali per menit
Pernafasan
: ...........kali per menit
Suhu
: ...........C
c. TB
: ...........cm
BB
:.........kg
d. Kepala dan leher
Oedem Wajah
: .........................................................................................................
Mata
: .........................................................................................................
Mulut
: .........................................................................................................
Leher
: .........................................................................................................
e. Payudara
Bentuk
: .........................................................................................................
Puting susu
: ........................................................................................................
Massa/ tumor
: .........................................................................................................
e. Abdomen
Bentuk
: .........................................................................................................
Bekas luka
: .........................................................................................................
Massa/tumor
: .........................................................................................................
f. Genetalia Luar
Bekas luka
: .........................................................................................................
Varises
: .........................................................................................................
Kelenjar Bartholini : .........................................................................................................
Pengeluaran
: .........................................................................................................
2. Pemeriksan Dalam/Ginekologis

3. Pemeriksaan Penunjang

ANALISA (Tanggal.. Jam..WIB)

POLTEKKES KEMENKES YOGYAKARTA

JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================
PENATALAKSANAAN (Tanggal.. Jam..WIB)

POLTEKKES KEMENKES YOGYAKARTA

JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================
.