MANAJEMEN KEBIDANAN PADA AKSEPTOR KB

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Tanggal Pengkajian :
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No. Register :
Diagnosa Masuk :

I. PENGKAJIAN
A. Data Subjektif
1. IDENTITAS (BIODATA)
Nama Pasien : ................................................ Nama Suami
: ................................................
Umur : ................................................ Umur
: ................................................
Suku / Bangsa : ................................................ Suku / Bangsa
: ................................................
Agama : ................................................ Agama
: ................................................
Pendidikan : ................................................ Pendidikan
: ................................................
Pekerjaan : ................................................ Pekerjaan
: ................................................
Penghasilan : ................................................ Penghasilan
: ................................................
Alamat Rumah
: ..........................................................................................................................................
.
..............................................................................................................................................
............................
2. KELUHAN UTAMA
.............................................................................................................................................
...........................
.............................................................................................................................................
...........................
.............................................................................................................................................
...........................

3. ALASAN KUNJUNGAN SAAT INI

Kunjungan pertama Kunjungan rutin
Kunjungan ulang
.............................................................................................................................................
...........................
.............................................................................................................................................
...........................

4. RIWAYAT MENSTRUASI
Menarche : ................................................ HPHT
: ................................................
Lama Haid : ................................................ HPL / HTP
: ................................................
Banyaknya : ................................................
Siklus : ................................................
 Teratur / Tidak : ................................................
Sifat darah : encer / beku
Dismenorhoe : ................................................
Flour Albus : ................................................
Jumlah : ................................................
Warna / Bau : ................................................

5. RIWAYAT KEHAMILAN, PERSALINAN, NIFAS YANG LALU

Persalinan Nifas Ket
Perka
Hamil Tempat Jenis Komplikasi Anak Lakta Komplika
winan Penolon
ke Persalin UK Persalin si si
ke : g
an an Ibu Bayi JK BB PB

6. RIWAYAT KONTRASEPSI YANG DIGUNAKAN

N Jenis Mulai memakai Berhenti / Ganti cara
o kontrasepsi Tanggal Oleh Tempat Keluhan Tanggal Oleh Tempat Alasan

7. RIWAYAT PENYAKIT YANG SEDANG DIDERITA

8. RIWAYAT PENYAKIT YANG LALU

9. RIWAYAT PENYAKIT KETURUNAN

10.RIWAYAT KESEHATAN
a. Pola nutrisi Makan Minum
Frekuensi ............................................ ............................................
Macam ............................................ ............................................
Jumlah ............................................ ............................................
Keluhan ............................................ ............................................
b. Pola eliminasi BAB BAK
Frekuensi ............................................ ............................................
Warna ............................................ ............................................
Bau ............................................ ............................................
Konsistensi ............................................ .....................................
.......
Jumlah ............................................ ............................................
Keluhan ............................................ ............................................
c. Pola aktivitas
Kegiatan sehari hari ............................................ ............................................
Istirahat / tidur ............................................ ............................................
d. Seksualitas
Frekuensi ............................................ ............................................
Keluhan ............................................ ............................................
e. Personal Hygiene
Kebiasaan mandi ................................................ kali / hari
 Kebiasaan membersihkan alat
kelamin ................................................................................
Kebiasaan mengganti pakaian
dalam ...................................................................................

11.RIWAYAT PSIKOSOSIAL
a. Pengetahuan ibu tentang alat kontrasepsi
........................................................................................................................................
....................
........................................................................................................................................
....................
b. Pengetahuan ibu tentang alat kontrasepsi yang dipakai sekarang
........................................................................................................................................
....................
........................................................................................................................................
....................
c. Dukungan suami / keluarga
........................................................................................................................................
....................
........................................................................................................................................
....................

12.KEPERCAYAAN / ADAT ISTIADAT

13.PERTANYAAN YANG DIAJUKAN

B. Data Objektif
1. Pemeriksaan umum
: .........................................................................................................................
Keadaan umum
: .........................................................................................................................
Kesadaran
: .........................................................................................................................
Tanda Vital
a. Tekanan darah
: .........................................................................................................................
b. Nadi
: .........................................................................................................................
c. Pernafasan
: .........................................................................................................................
d. Suhu
: .........................................................................................................................
BB / TB
: .........................................................................................................................
2. Pemeriksaan Fisik
a. Kepala
- Edema wajah
: ........................................................................................................................
- Rambut : Warna
rambut ................................................................................................
Rontok /
tidak .................................................................................................

Benjolan ..............................................................................................
...........
 Ketombe .............................................................................................
...........
- Mata : Kelopak
mata .................................................................................................

Konjungtiva .........................................................................................
...........

Sklera ..................................................................................................
...........
- Hidung :
Sekresi ............................................................................................................

Simetris ...............................................................................................
...........

Polip ....................................................................................................
...........
- Telinga :
Serumen ........................................................................................................
- Mulut dan gigi :
Lidah ..............................................................................................................

Gusi .....................................................................................................
...........

Gigi ......................................................................................................
...........
b. Leher
- Pembesaran kelenjar
thyroid ........................................................................................................
- Pembesaran vena
jugularis ...........................................................................................................
c. Dada
- Mamae :
Membesar ..................................................................................................................
.

Simetris .........................................................................................................
..............

Areola ............................................................................................................
.............
Puting
susu................................................................................................................
..

Pengeluaran ...................................................................................................
.............
Benjolan /
tumor .........................................................................................................
- Axilla : Pembesaran kelenjar
limfe .........................................................................................

d. Abdomen
- Pembesaran / benjolan
: ...........................................................................................................
- Bekas luka operasi
: ...........................................................................................................
 e. Anogenital
- Tanda Chadwich
: ...........................................................................................................
- Varises
: ...........................................................................................................
- Bekas luka
: ...........................................................................................................
- Kelenjar bartholini
: ...........................................................................................................
- Pengeluaran : .................................................................................................
..........
- Hemoroid : .................................................................................................
..........
f. Ekstremitas
- Oedema
: ...........................................................................................................
- Varises : .................................................................................................
..........
- Reflek patela
: ...........................................................................................................

3. Palpasi
- Payudara
: ......................................................................................................................
- Abdomen
: ......................................................................................................................
4. Inspeculo
- Vagina
: ......................................................................................................................
- Serviks : ...........................................................................................................
...........

5. Pemeriksaan bimanual
.............................................................................................................................................
.....................
.............................................................................................................................................
.....................

6. Pemeriksaan Laboratorium
.............................................................................................................................................
.....................
.............................................................................................................................................
.....................

7. Pemeriksaan penunjang lain

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II. INTERPRETASI DATA
N TANGGAL DATA DASAR DIAGNOSA / MASALAH
O JAM / KEBUTUHAN
III. INTERVENSI / PERENCANAAN
N TANGGAL DIAGNOSA / MASALAH / INTERVENSI RASIONAL
O JAM KEBUTUHAN
IV. IMPLEMENTASI / PELAKSANAAN
N TANGGAL DIAGNOSA / MASALAH / IMPLEMENTASI
O JAM KEBUTUHAN

V. EVALUASI
N TANGGAL DIAGNOSA / EVALUASI
O JAM MASALAH /
KEBUTUHAN