ASUHAN KEBIDANAN PADA AKSEPTOR KB

LANGKAH I
Tanggal : ……………………. Jam : ……………………
Oleh : …………………….
Pengkajian
A. Identitas
Nama klien : ……………………. Nama suami : ……………………
Umur : ……………………. Umur : ……………………
Suku : ……………………. Suku : ……………………
Agama : ……………………. Agama : ……………………
Pendidikan : ……………………. Pendidikan : ……………………
Pekerjaan : ……………………. Pekerjaan : ……………………
Alamat : ……………………. Alamat : ……………………

B. Anamnese
1. Alasan kunjungan : …………………………………………………………….
…………………………………………………………….
2. Keluhan : ………………………………………………………….....
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3. Riwayat Obstetri dan Gynekologi
a) Riwayat menstruasi
- HPHT : …………………………………………………….
- Lamanya : …………………………………………………….
- Siklus : …………………………………………………….
- Banyaknya : …………………………………………………….
- Warna : …………………………………………………….
- Konsistensi : …………………………………………………….
- Dysmenorhoe : …………………………………………………….
- Menarche : …………………………………………………….
- Teratur / tidak : …………………………………………………….
- Keluhan lain : …………………………………………………….
b) Keputihan
- Banyaknya : …………………………………………………….
- Warna : …………………………………………………….
- Bau / Gatal : …………………………………………………….
c) Perdarahan jalan lahir
- Pernah / tidak pernah : …………………………………………………..
- Kapan : …………………………………………………..
- Lamanya : …………………………………………………..
- Warnanya : …………………………………………………..
- Disertai rasa nyeri : …………………………………………………..
d) Riwayat Ginekologi
- Mioma Uteri : …………………………………………………...
 - Kista :
…………………………………………
………...
- Mola Hidatidosa : …………………………………………………...
- PMS / HIV / AIDS : …………………………………………………...
- PID : …………………………………………………..
- Endometriosis : …………………………………………………..
- KET : …………………………………………………..
- Operasi : …………………………………………………..
4. Kehamilan yang lalu
- Umur kehamilan : …………………………………………………….
- Jumlah kehamilan : …………………………………………………….
- Abortus : …………………………………………………….
- Partus : …………………………………………………….
- Lahir hidup : …………………………………………………….
5. Riwayat menyusui
- Anak I : ……… Lamanya : ……… Alasan : ……………
- Anak II : ……… Lamanya : ……… Alasan : ……………
- Anak III : ……… Lamanya : ……… Alasan : ……………
- Anak IV : ……… Lamanya : ……… Alasan : ……………
6. Riwayat Kesehatan
- Penyakit jantung : …………………………………………………….
- Hypertensi : …………………………………………………….
- Hepar : …………………………………………………….
- DM : …………………………………………………….
- Anemia : …………………………………………………….
- PMS/HIV/AIDS : …………………………………………………….
- Campak : …………………………………………………….
- Malaria : …………………………………………………….
- Tubercolosis :..................................................................................
- Gangguan Mental : .................................................................................
- Operasi : .................................................................................
- Haemorroid : .................................................................................
- Alergi : .................................................................................
 Makanan : .................................................................................
 Obat – obatan : ……………………………………………………
7. Riwayat KB
- Pernah mengikuti KB :
……………………………………………
- Jenis kontrasepsi :
……………………………………………
- Lama pemakaian :
…………………………………………….
- Ikut KB atas kemauan :
…………………………………………….
- Tempat Pelayanan :
…………………………………………….
- Keluhan selama memakai :
…………………………………………….
- Pengetahuan Ibu tentang KB :
…………………………………………….
 - Kontrasepsi yang digunakan sekarang:
……………………………………
8. Kebiasaan sehari – hari
- Obat – obatan / Jamu : …………………………………………………….
- Pola nutrisi
 Sebelum menggunakan KB : …………………………………….
 Selama menggunakan KB : …………………………………….
- Merokok : …………………………………….
- Aktivitas sehari – hari
 Di rumah : …………………………………….
 Di luar rumah : …………………………………….

- Pola istirahat / tidur

 Siang : …………………………………….
 Malam : …………………………………….
- Pola seksual
 Frekuensi : …………………………………….
 Keluhan : …………………………………….
C. Pemeriksaan
1. Pemeriksaan Umum
- Keadaan umum : …………………………………………………….
- Kesadaran : …………………………………………………….
- BB / TB : …………………………………………………….
- Ekspresi wajah : …………………………………………………….
- Keadaan emosional :
…………………………………………………….
- Tanda – tanda vital
 Tekanan darah : ……………………………………………………
 Suhu tubuh : ……………………………………………………
 Nadi : …………………………………………………….
 Pernapasan : …………………………………………………….
2. Pemeriksaan Fisik
a. Inspeksi
- Muka : …………………………………………………….
- Mata : ………………………………………….…………
- Leher : …………………………………………………….
- Ketiak : …………………………………………………….
- Abdomen : …………………………………………………….
- Genetalia : …………………………………………………….
- Anus : …………………………………………………….
- Ekstremitas : …………………………………………………….
b. Palpasi
- Leher : …………………………………………………….
- Axilla : …………………………………………………….
- Payudara : …………………………………………………….
- Abdomen : …………………………………………………….
- Tungkai : …………………………………………………….
c. Auskultasi
- Paru – paru
Wheezing : …………………………………………………….
Ronchi : …………………………………………………….
 - Jantung
Irama : …………………………………………………….
Frekuensi : …………………………………………………….

d. Perkusi
- Dada : …………………………………………………….
- Perut : …………………………………………………….
- Ekstremitas : …………………………………………………….
- Refleks patella
 Kanan / Kiri : …………………………………………………….

3. Pemeriksaan khusus
a. Pemeriksaan inspecullo : ……………………………………………
b. Pemeriksaan dalam : ……………………………………………
c. Pemeriksaan laboratorium : …………………………………………….
LANGKAH II
INTERPRESTASI DATA DASAR
1. Diagnosa
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2. Masalah
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LANGKAH III
MENGIDENTIFIKASI DIAGNOSA ATAU MASALAH POTENSIAL
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LANGKAH IV
MENETAPKAN KEBUTUHAN TERHADAP TINDAKAN SEGERA
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LANGKAH V
MENYUSUN RENCANA ASUHAN YANG MENYELURUH
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LANGKAH VI
PELAKSANAAN LANGSUNG ASUHAN / IMPLEMENTASI
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LANGKAH VII
EVALUASI
Tanggal: Pukul :
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