1 Format Laporan

Askeb Keluarga Berencana

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No. Register : .
Masuk RS/PKM/BPM Tanggal/Pukul : .
Dirawat diruang : .....

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 : ................................................ .......................................................
8. No. Telp : ................................................ .......................................................

B. Data Subjektif
1. Alasan datang
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2. Keluhan Utama
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3. Riwayat Menstruasi
Menarche : ................................. Siklus : .........................................
Lama : ................................. Teratur : .........................................
Sifat darah : ................................. Keluhan : .........................................

4. Riwayat perkawinan
Status pernikahan : .......................... Menikah ke : .........................................
Lama : .......................... Usia menikah pertama kali : .....................

Program Studi D III Kebidanan UNRIYO T.A 2013/2014

 2 Format Laporan
Askeb Keluarga Berencana

5. Riwayat kehamilan,persalinan,dan nifas yang lalu P....... A...... Ah........

Hamil Persalinan Nifas
ke- Tanggal Umur Jns Penolong komplikasi JK BB Laktasi Komplikasi

6. Riwayat Penggunaan Alat Kontrasepsi : P ....... A ....... Ah .......

No Jenis Pasang Lepas
Tgl Oleh Tempat Keluhan Tgl. Oleh Tempat Alasan
. Kontrasepsi

7. Riwayat Laktasi
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8. Riwayat kesehatan
a. Penyakit yang pernah/sedang diderita (menular, menurun dan menahun)
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b. Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan menahun)




c. Riwayat keturunan kembar


d. Riwayat rawat inap dan operasi
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e. Riwayat alergi obat

Program Studi D III Kebidanan UNRIYO T.A 2013/2014

 3 Format Laporan
Askeb Keluarga Berencana

9. Pola pemenuhan kebutuhan

a. Nutrisi
Makan Minum
Frekuensi : ...... xhari ...... x/hari
Jenis : .................................... ....................................
Porsi : .................................... ....................................
Pantangan : .................................... ....................................
Keluhan : .................................... ....................................
b. Eliminasi
BAK BAB
Frekuensi : ........ x/hari ......... x/hari
Warna : ................................... ...................................
Konsistensi : ................................... ...................................
Keluhan : ................................... ...................................
c. Istirahat
Tidur Siang Tidur Malam
Lama : ....... jam/hari ........ jam/hari
Keluhan : ................................... ..................................
d. Personal Hygiene
Mandi : ....... x/hari
Ganti pakaian : ....... x/hari
Gosok gigi : ....... x/hari
Keramas : ....... x/minggu
e. Pola seksualitas
Frekuensi : ....... x/minggu
Keluhan : ...................................
f. Pola aktivitas (terkait kegiatan fisik, olah raga)
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10. Data psikososial, spiritual dan ekonomi (pengetahuan ibu dan keluarga tentang
kontrasepsi, pengambilan keputusan, kegiatan ibadah, kegiatan sosial, keadaan ekonomi
keluarga)
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C. Data Objektif
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 4 Format Laporan
Askeb Keluarga Berencana

1. Pemeriksaan umum
Keadaan umum : ..................................................................................
Kesadaran : ..................................................................................
Status emosional : ..................................................................................
Tanda vital : ..................................................................................
Tekanan darah : ................. mmHg Nadi ......... x/menit
Pernafasan : ................ x/menit Suhu ......... 0C
BB : ................kg TB .......... cm

2. Pemeriksaan fisik
Kepala
: ....................................................................................................................
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Wajah
: ....................................................................................................................
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Mata
: ....................................................................................................................
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Hidung
: ....................................................................................................................
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Mulut
: ....................................................................................................................
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Telinga
: ....................................................................................................................
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Leher
: ....................................................................................................................
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Dada
: ....................................................................................................................
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Payudara
: ....................................................................................................................
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Abdomen
: ....................................................................................................................
Program Studi D III Kebidanan UNRIYO T.A 2013/2014
 5 Format Laporan
Askeb Keluarga Berencana

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Ekstermitas
Atas
: ....................................................................................................................
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Bawah
: ....................................................................................................................
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Genetalia luar
: ....................................................................................................................
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3. Pemeriksaan penunjang Tgl : .............................. Pukul : .................... WIB

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4. Data penunjang
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II. INTERPRESTASI DATA

A. Diagnosa kebidanan
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Data Dasar :

Program Studi D III Kebidanan UNRIYO T.A 2013/2014

 6 Format Laporan
Askeb Keluarga Berencana

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B. Masalah
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Data Dasar :
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III. IDENTIFIKASI DAN ANTISIPASI DIAGNOSAL POTENSIAL

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IV. TINDAKAN SEGERA

A. Mandiri
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B. Kolaborasi
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C. Merujuk

Program Studi D III Kebidanan UNRIYO T.A 2013/2014

 7 Format Laporan
Askeb Keluarga Berencana

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

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

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Program Studi D III Kebidanan UNRIYO T.A 2013/2014
 8 Format Laporan
Askeb Keluarga Berencana

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VII. EVALUASI Tanggal : .............................. Pukul : ................... WIB

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Program Studi D III Kebidanan UNRIYO T.A 2013/2014

 9 Format Laporan
Askeb Keluarga Berencana

Pembimbing Institusi Pembimbing Lapangan Mahasiswa

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Program Studi D III Kebidanan UNRIYO T.A 2013/2014