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KEMENTERIAN KESEHATAN RI

BADAN PENGEMBANGAN DAN PEMBERDAYAAN SDM KESEHATAN


POLITEKNIK KESEHATAN MATARAM
Jalan Prabu Rangkasari Dasan Cermen Cakranegara-Mataram
Telepon (0370) 631160-621383 Faximile (0370) 621383
Website: www.poltekkesmataram.ac.id, Email:admin@poltekkesmataram.ac.id

FORMAT (SOAP) ASKEB PADA IBU BERSALIN

No MR : .........................................................................................................................
Masuk tgl/jam : .........................................................................................................................
Tempat: .........................................................................................................................

PENGKAJIAN
Tanggal/Jam : .................................................................................

KALA I :
A. SUBYEKTIF (S)
1. Identitas Istri Suami
Nama :.............................. .........................
Umur :.............................. .........................
Agama :.............................. ..........................
Pendidikan :.............................. ..........................
Pekerjaan :.............................. ..........................
Suku/bangsa :.............................. ..........................
Alamat :.............................. ..........................

2. Anamnesa
a. Keluhan Utama


.....

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.
.

b. Riwayat Perjalanan Penyakit


.
.
.
.
.
.
.
c. Riwayat Perkawinan
1) Perkawinan ke : ......................................................................................
2) Menikah sejak umur : ......................................................................................
3) Lama perkawinan : ......................................................................................
4) Status perkawinan : ......................................................................................

d. Riwayat Kehamilan, Persalinan dan Nifas yang lalu


Riwayat
BBL Ket
Hamil UK Tempat Penolong Jenis penyulit
ke (bln) persalinan persalinan persalinan BB J Umur
H P N
(gr) K (thn)

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e. Riwayat KB
1) KB yang digunakan sebelumnya : ...............................................................
2) Keluhan selama menggunakan KB : ...............................................................
3) Rencana KB : ...............................................................

f. Riwayat Kesehatan
1) Riwayat Kesehatan Yang Lalu
: ............................................................... ................................................
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2) Riwayat Kesehatan Sekarang
: ............................................................... ................................................
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3) Riwayat Kesehatan Keluarga
: ............................................................... ................................................
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g. Riwayat Kehamilan Sekarang


a) ANC di................................................sejak umur kehamilan..................bulan
b) HPHT : ..............................................................................................................
c) Gerakan janin dirasakan sejak usia kehamilan.......................bulan dan masih
dirasakan sejak 24 jam terakhir
d) Frekuensi periksa TMI................kali, TMII................kali, TMIII...............kali
e) Senam hamil......................................................................................................
f) Obat obatan yg pernah dikonsumsi : ................................................................

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h. Permasalahan dan Keluhan Dalam Kehamilan (jika ada)
Trimester Masalah/keluhan Tindakan/terapi
I
II
III

i. Pola kebutuhan sehari-hari


1) Nutrisi
a) Porsi makan : ..........................................................................
b) Makan terakhir : jam....................................................................
c) Jenis : ..........................................................................
d) Makanan pantangan : ..........................................................................
e) Minum terakhir : jam....................................................................
f) Keluhan : ..........................................................................
2) Eliminasi
a) BAK
Frekuensi...............kali/hari, jumlah..................., warna...........................
Keluhan....................................................................................................
b) BAB
Frekuensi...............kali/hari, konsistensi..................., warna....................
Keluhan....................................................................................................
3) Istirahat
Siang................................................, malam...................................................
Keluhan...........................................................................................................
4) Aktivitas terakhir :
5) Personal hygiene terakhir :
6) Pola seksual terakhir :

j. Data Psikososial Spiritual


1) Kesiapan ibu menghadapi persalinan dan keluarga : ......................................
.........................................................................................................................
2) Pengambilan keputusan : ................................................................................
3) Tanggapan ibu dan keluarga terhadap kehamilan ini : ...................................
........................................................................................................................
4) Pengetahuan ibu dan keluarga tentang kehamilan : .......................................

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........................................................................................................................
5) Pengambilan keputusan oleh : ........................................................................
6) Ibu tinggal bersama : ......................................................................................

B. OBYEKTIF (O)
1. Pemeriksaan umum
Keadaan umum ibu : .....................................................................................
Kesadaran : .....................................................................................
Emosi : .....................................................................................
HTP : .....................................................................................
TB : ....................cm
BB sebelum hamil : ....................kg
BB sekarang : ....................kg
Lila : ....................cm
Tanda tanda vital : Tekanan darah : .......................................mmHg
Nadi : ......................................x/menit
Respirasi : ......................................x/menit
Suhu : ..............................................C

2. Pemeriksaan fisik
a. Wajah
1) Inspeksi : .................................................................................................
2) Palpasi : .................................................................................................
b. Mata : .................................................................................................
c. Mulut dan gigi : .................................................................................................
d. Leher : .................................................................................................
e. Payudara
1) Inspeksi : .................................................................................................
2) Palpasi : .................................................................................................
f. Ekstremitas
1) Ekstremitas Atas : ......................................................................................
2) Ekstremitas Bawah : ......................................................................................

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3. Pemeriksaan Obstetri
a. Abdomen
1) Inspeksi : ..................................................................................................
2) Palpasi
Leopold I : TFU............jari........................(......cm), teraba........................
Leopold II : ..................................................................................................
Leopold III : ..................................................................................................
Leopold IV : ..................................................................................................
TBJ :
His : .......x dalam 10 menit, lama.............detik, intensitas...............
3) Auskultasi : DJJ (.....), irama : ......-......-......, frekuensi :......................x/menit
b. Genetalia
1) Inspeksi : ........................................................................................................
2) Pemeriksaan dalam, tanggal......................................., pukul..........................
VT ..........cm, eff............ %,ketuban (.........), warna (.......................),
teraba..................................., denominator............................................,
penurunan kepala di H.........., tidak teraba bagian kecil janin dan tali pusat.

4. Pemeriksaan Penunjang (Jika dilakukan)


a. Urine : tgl.....................................................
1) PP test : ..................................
2) Protein urine : ..................................
3) Glukosa urine : ..................................
4) Dll : ..................................
b. Darah : tgl......................................................
1) Hb : ..................................gr %
2) Al : ..................................
3) HMT : ..................................
4) Golongan darah : ..................................

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C. ANALISA (A)
1. Diagnosa :
Ibu : G...P...A...H..., umur kehamilan...............minggu, KU Ibu................dengan
inpartu kala I fase...........................................................................................
Janin : Janin Tunggal, Hidup, Intrauterin, presentasi kepala, KU Janin....................
2. Masalah : ................................................................................................
3. Diagnosa Potensial : ................................................................................................

D. PENATALAKSANAAN (P) Tgl/Jam : .........................................................


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Lembar Observasi :

Pengeluaran
Tgl HIS DJJ TTV Keluhan Ket.
pervaginam
Jam
Frek Lama Intens +/- Frek Irama TD N S

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Pengeluaran
Tgl HIS DJJ TTV Keluhan Ket.
pervaginam
Jam
Frek Lama Intens +/- Frek Irama TD N S

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KALA II
Tanggal : ........................................................................................................................
Pukul : ........................................................................................................................
Tempat: ........................................................................................................................

A. Subyektif (S)
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B. Obyektif (O)
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C. Analisa (A)
Kala II

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D. Penatalaksanaan (P)
Tgl/Jam : ..........................................................
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Tabel 2.1 Penilaian keadaan bayi dengan APGAR SCORE

Aspek yang 1 menit


No Nilai 5 menit kedua Nilai
dinilai pertama
1 Appearance
(Penampilan)
2 Pulse
(Denyut Jantung)
3 Grimace (Reaksi
terhadap
rangsangan)
4 Activity (Tonus
Otot)
5 Respiration
(Pernafasan)
Jumlah

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KALA III
Tanggal : ........................................................................................................................
Pukul : ........................................................................................................................
Tempat: ........................................................................................................................

A. Subyektif (S)
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B. Obyektif (O)
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C. Analisa (A)
Kala III

D. Penatalaksanaan (P)
Tgl/Jam : ..........................................................
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KALA IV
Tanggal : ........................................................................................................................
Pukul : ........................................................................................................................
Tempat: ........................................................................................................................

A. Subyektif (S)
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B. Obyektif (O)
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C. Analisa (A)
Kala IV

D. Penatalaksanaan (P)
Tgl/Jam : ..........................................................
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Tabel 3.3 Pemantauan 2 jam PP


Jam Kandung Jumlah
Waktu TD N S TFU CUT
ke- kemih perdarahan

II
Evaluasi Tgl/Jam : .............................................................................................
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Mengetahui,
Mahasiswa

(.............................................)
Bidan Pendamping Pembimbing Lahan

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(.............................................) (.............................................)
Pembimbing Pendidikan

(.............................................)

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