MANAGEMENT ASUHAN KEBIDANAN

PADA ASEPTOR KB

Tgl masuk : jam :

Ruangan : no.Mr
:

Tgl pengkajian : dikaji oleh mhs :

1. Pengkajian data
A. Data subjektif
1. Identitas Alamat
Nama ibu :_______________
:_______________ _
_
Umur Nama suami
:_______________ :_______________
_ Umur
Agama :_______________
:_______________ Agama
_ :_______________
Suku Suku
:_______________ :_______________
_ Pendidikan
Pendidikan :_______________
:_______________ Pekerjaan
_ :_______________
Pekerjaan Alamat
:_______________ :_______________
_

2. Alasan kunjungan
:____________________________________________________________

3. Riwayat menstruasi
Menarche :_____________________________________
Siklus haid :_____________________________________
Teratur :_____________________________________
Keluhan :_____________________________________
HPHT :_____________________________________

4. Riwayat KB
Alkon terakhir yang digunakan :_________________________________
Alasan memakai alkon terakhir :_________________________________
Kapan mulai menggunakan alkon terakhir
:_________________________________
Petugas yang memberikan alkon terakhir:_________________________________
 Kapan berenti menggunakan alkon terakhir
:_________________________________
Alasan berenti menggunakan alkon :_________________________________
Petugas yang melepaskan alkon terakhir :_________________________________

5. Riwayat penyakit yang diderita dan sedang di derita ibu

(jantung, hipertensi, TBC, anemia, PMS, DM, dll)
:____________________________

6. Riwayat kehamilan, persalinan, dan nifas yang lalu

:____________________________

7. Pola kegiatan sehari-hari

a. Istirahat
Siang :__________________
Malam :__________________
Keluhan :__________________
b. Nutrisi
-Makan
Jenis :__________________
Frekuensi :__________________
-Minum
Jenis :__________________
Frekuensi :__________________
c. Aktifitas
Kegiatan sehari-hari :__________________
d. Seksualitas
Frekuensi :__________________
Keluhan :__________________

8. Riwayat perkawinan
Kawin...kali :__________________
Kawin pertama usia :__________________
Lama perkawinan :__________________

B. Data objektif
1. Pemeriksaan umum
Keadaan umum :_________________________
Kesadaran :_________________________
Emosional :_________________________
Tanda tanda vital
TD :______________________
N :______________________
BB :______________________
P :______________________
N :______________________

2. Pemeriksaan khusus
a. Mata
Kelopak mata :_____________________
Konjungtiva :_____________________
 Sklera :_____________________
b. Leher
Pembesaran kelenjar tyroid :____________________
Pembesaran kelenjar getah bening :____________________
c. Dada
Bentuk payudara :_____________________
Benjolan/tumor :_____________________
Bekas luka :_____________________
d. Perut
Pembesaran :_____________________
Benjolan/tumor :_____________________
Bekas luka :_____________________
e. Vulva
Klistoris :_____________________
Orifisium uretra :_____________________
Orifisium vagina :____________________
Perenium :____________________
Anus :____________________
f. Ekstermitas
Oedema :____________________
Varices :____________________
Kekakuan sendi :____________________

3. Pemeriksaan penunjang
Darah :____________________
Urine :____________________
USG :____________________
Rontgen :____________________
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