1 Format Laporan

Askeb Pada Ibu Hamil

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No. Register : .
Masuk RS tanggal / jam : .....
Dirawat diruang : ....................................................................................................

PENGKAJIAN Tanggal : .... Jam : WIB, Oleh : ..

A. DATA SUBYEKTIF
Biodata Ibu Suami
Nama : . ...
Umur : . ...
Agama : . ...
Suku/Bangsa : ............................................ .......................................................
Pendidikan : .............................................. .......................................................
Pekerjaan :.............................................. .......................................................
Alamat :.............................................. .......................................................
............................................... .......................................................
No. Telepon : ...

1. Alasan kunjungan
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2. Keluhan Utama
...
...
...

3. Riwayat Menstruasi
Menarche : Tahun Sifat darah : .........................................
Lama : hari Teratur : .
Siklus : hari Keluhan : ........................................

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

5. Riwayat Obstetrik : G...............P........... A.............Ah...........

Program Studi D III Kebidanan UNRIYO TA.2013/2014
 2 Format Laporan
Askeb Pada Ibu Hamil

Hamil Persalinan Nifas

Umur Jenis
ke- Tanggal Penolong komplikasi JK BB Lahir Laktasi Komplikasi
khamiln prsalinan

6. Riwayat Kontrasepsi Yang Digunakan

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

7. Riwayat Kehamilan Sekarang

a. HPHT : .......................... HPL : ............................
b. ANC pertama umur kehamilan : minggu
c. Kunjungan ANC
Trimester I
Frekuensi : .......... x, Tempat : .. Oleh : ...................................
Keluhan : ...............................................................................................................
Terapi : ...
Trimester II
Frekuensi : ......... x, Tempat : Oleh : ...
Keluhan : ...
Terapi : ...
Trimester III
Frekuensi : ........ x, Tempat : .......................... Oleh : ..............................
Keluhan : ...
Terapi : ...............................................................................................................
d. Imunisasi TT : ................. kali
TT 1 : tanggal ................................
TT 2 : tanggal ................................
TT 3 : tanggal .
TT 4 : tanggal .
TT 5 : tanggal
e. Pergerakan janin selama 12 jam(dalam sehari)
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..
8. Riwayat kesehatan
a. Penyakit yang pernah /sedang diderita (menular, menurun dan menahun)
Program Studi D III Kebidanan UNRIYO TA.2013/2014
 3 Format Laporan
Askeb Pada Ibu Hamil

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b. Penyakit yang pernah /sedang diderita keluarga (menular, menurun dan menahun)
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...
c. Riwayat keturunan kembar
.

.

.
d. Riwayat operasi
.

.
e. Riwayat alergi obat
.

.

9. Pola pemenuhan kebutuhan sehari-hari

a. Pola nutrisi sebelum hamil saat hamil
Makan
Frekuensi :......... x/hari .......... x/hari
Porsi :............................................ ...............................................
Jenis :............................................ ...............................................
Pantangan :............................................ ................................................
Keluhan :........................................... ................................................
Minum
Frekuensi :.......... x/hari .......... x/hari
Porsi :.............................................. ................................................
Jenis :.............................................. ................................................
Pantangan :.............................................. ................................................
Keluhan :.............................................. ................................................
b. Pola eliminasi
BAB
Frekuensi :.......... x/hari .......... x/hari
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 4 Format Laporan
Askeb Pada Ibu Hamil

Konsistesi :............................................. ..............................................

Warna :............................................. ...............................................
Keluhan :............................................ ..............................................
BAK
Frekuensi :........ x/hari ......... x/hari
Konsistesi :............................................ ...............................................
Warna :............................................ ..............................................
Keluhan :............................................ ...............................................
c. Pola istirahat
Tidur siang
Lama : ........ jam ........ jam
Keluhan :............................................. ............................................
Tidur malam
Lama : ........ jam ......... jam
Keluhan :............................................. ..............................................
d. Personal hygiene
Mandi : ........ x/hari ........ x/hari
Ganti pakaian :......... x/hari ........ x/hari
Gosok gigi :......... x/hari ........ x/hari
Keramas :........ x/minggu ........ x/minggu
e. Pola seksualitas
Frekuensi :........ x/minggu ......... x/minggu
Keluhan :.......................................... ...............................................

10. Pola aktivitas (terkait kegiatan fisik, olah raga)

...
...
...
...

11. Kebiasaan yang mengganggu kesehatan ( merokok,minum jamu,minuman

beralkohol)
...
...

...

...
Program Studi D III Kebidanan UNRIYO TA.2013/2014
 5 Format Laporan
Askeb Pada Ibu Hamil

12. Psikososiospiritual ( penerimaan ibu/suami/keluarga terhadap kehamilan,

dukungan sosial, perencanaan persalinan,pemberian ASI, perawatan bayi, kegiatan
ibadah, kegiatan sosial, dan persiapan keuangan ibu dan keluarga)
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13. Pengetahuan ibu ( tentang kehamilan,persalinan,dan laktasi)

...
...

...

...
...

14. Lingkungan yang berpengaruh ( sekitar rumah dan hewan peliharaan)

...
...

...
...

....
..

B. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum : .
Kesadaran : .
Status emosional : .....................................................................
Program Studi D III Kebidanan UNRIYO TA.2013/2014
 6 Format Laporan
Askeb Pada Ibu Hamil

Tanda vital sign :

Tekanan darah : .. mmHg Nadi : ........... x/menit
Pernapasan : ............. xmenit Suhu : .......... 0C
BB sebelum hamil : ............ kg Tinggi badan : ......... cm
BB sesudah hamil : ........... kg
2. Pemeriksaan fisik
Kepala : ........................................................................................................................
........................................................................................................................
Muka : ........................................................................................................................
....
Mata : .......................................................................................................................
....
Hidung : ........................................................................................................................

Mulut : ........................................................................................................................

Telinga : ........................................................................................................................
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Leher : ........................................................................................................................
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Dada :
........................................................................................................................
Payudara: .........................................................................................................................
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Abdomen: .........................................................................................................................
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Palpasi Leopold
Leopold I : ..

Leopold II : ..

Leopold III: ..

Leopold IV: .

Osborn test : .................................................................................................................

TFU menurut Mc. Donald : cm, TBJ : gram

Program Studi D III Kebidanan UNRIYO TA.2013/2014

 7 Format Laporan
Askeb Pada Ibu Hamil

Auskultasi DJJ : ........................................................................................

Ekstremitas atas : .........................................................................................
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Ekstremitas bawah : .........................................................................................
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Genetalia luar : .....................................................................................................
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Anus : ....................................................................................................
Pemeriksaan panggul (bila perlu) : .............................................................................
.
.

.

3. Pemeriksaan Penunjang Tanggal : pukul : WIB

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C. ANALISA
Diagnosa Kebidanan
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Data Dasar
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Program Studi D III Kebidanan UNRIYO TA.2013/2014
 8 Format Laporan
Askeb Pada Ibu Hamil

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D. PENATALAKSANAN
Tanggal............................
Pukul Tindakan, Evaluasi
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Program Studi D III Kebidanan UNRIYO TA.2013/2014
 9 Format Laporan
Askeb Pada Ibu Hamil

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Pembimbing Institusi Pembimbing Lapanagn Mahasiswa

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Program Studi D III Kebidanan UNRIYO TA.2013/2014