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KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENKES MALANG


JURUSAN KEBIDANAN
PROGRAM STUDI D-III KEBIDANAN KEDIRI
TAHUN 2014/2015
Jl. KH. Wakhid Hasyim No. 64 B Telp. (0354) 773095 – 772833
Website :http://www.poltekkes-malang.ac.id

Format Asuhan Kebidanan Pada Ibu bersalin (INC)

I. Pengkajian

Tanggal : Jam :
No. RM :
Nama : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat : Alamat :

Cara masuk :

Datang Sendiri Rujukan dari :

Diagnose

A. DATA SUBYEKTIF
1. Keluhan
utama : ...................................................................................................................................
................................................................................................................................................
.............

2. Riwayat menstruasi
 Usia manarche :
 Jumlah darah haid :
 HPHT :
 Keluhan saat haid :
 Lama haid :
 Flour albus :
 TP :
 Keluhan haid :

Disminorhoe Spoting Menorrhagia Premenstrual syndrome

Dll..............

3. Riwayat hamil ini


 Hamil muda :
Mual Muntah Perdarahan lain-lain(isi sesuai keluhan)
 Hamil tua :
Pusing Sakit Kepala Perdarahan Lain-lain(isi sesuai keluhan)
 Riwayat imunisasi : TT1 TT2
 Gerakan janin pertama :..................bulan
 Gerakan janin
terakhir :..........................................................................................................
 Tanda bahaya dan penyulit
kehamilan :.................................................................................
 Obat/jamu yang pernah dan sedang di
konsumsi :................................................................
 Keluhan BAK :........... Keluhan BAB :........................
 Kekhawatiran
khusus : ............................................................................................................................
....

4. Riwayat kehamilan,persalinan, dan nifas yang lalu.


G............................p.............................A.........................Hidup..............................

Tahun Tempat Usia Jenis Penyulit Anak


No. Penolong KB Lama
Persalinan Persalinan Kehamilan Persalinan Persalinan JK BB PB

5. Riwayat kesehatan penyakit yang pernah diderita :


 Anemia
 Hipertensi
 Kardiovaskular
 TBC
 Diabetes
 Malaria
 IMS (Sphilis, GO, HIV/AIDS, dll)
 Lain-lain....
Pernah dirawat : ya/tidak Kapan : ........................... Dimana :.................
Pernah dioperasi : ya/tidak Kapan : ........................... Dimana :.................
Lain-lain
6. Riwayat penyakit keluarga (Ayah, Ibu, Mertua) yang pernah menderita sakit :
................................................................................................................................................

7. Status perkawinan : ya/tidak


Kawin.............kali, kawin usia..............tahun, lama menikah....................tahun

8. Riwayat psiko sosial ekonomi


- Respon ibu dan keluarga terhadap kehamilan
................................................................................................................................................

- Penggunaan alat kontrasepsi KB


................................................................................................................................................
- Dukungan keluarga
................................................................................................................................................

- Pengambilan keputusan dalam keluarga


................................................................................................................................................
- Gizi yang dikonsumsi dan kebiasaan makan
................................................................................................................................................
- Kebiasaan hidup sehat
................................................................................................................................................
- Beban kerja sehari
................................................................................................................................................
- Tempat dan penolong persalinan yang diinginkan
................................................................................................................................................
- Penghasilan keluarga
................................................................................................................................................

9. Riwayat KB dan rencana KB


Metode yang pernah dipakai : ......................................., Lama : ...................bulan/tahun
Komplikasi dari KB : ..................................., Rencana KB
selanjutnya: ..................................................................................................

10. Riwayat Ginekologi :


Infertilitas Infeksi virus PMS Endometritis
Polip servik Kanker kandungan Operasi kandungan Perkosaan
DUB dll........................

11. Pola makan / minum/ eliminasi/ istirahat


- Pola minum : .................gelas/hari alkohol Jamu Kopi
- Pola eliminasi :
BAK.................cc/hari, warna : jernih/kuning/kuning pekat/ groshematuri, BAK terakhir
jam :.........
BAB..................kali/hari, karakteristik: lembek/keras, BAB terakhir jam :.........................
- Pola istirahat : ............................jam/hari, tidur terakhir jam : ...................
- Dukungan keluarga : Suami Orang tua Mertua Keluarga lain

B. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum : Kesadaran :
BB/TB : Tekanan Darah:
Nadi : Suhu :
Pernafasan :

2. Pemeriksaan Fisik
- Mata : Konjungtiva : anemis/tidak Selera : Ikterik/tidak
Pandangan Kabur Adanya pemandangan dua
- Rahang, gigi, gusi : normal/tidak, gusi berdaarah/tidak
- Leher : adanya pembesaran vena jugularis / tidak, adanya pembesaran kelenjar
thyroid/tidak.
- Dada : aerola hiperpigmentasi Tumor Kolostrum
Puting susu menonjol/masuk ke dalam
- Axilla :
- Sistem respiratori : dispneu tachipneu wheezing
- Sistem kardio : Nyeri dada murmur palpitasi
- Pinggang :nyeri/tidak, skoliosis, lordosis, kiposis(coret yang tidak perlu)
- Ekstrimitas atas dan bawah : tungkai simetris/asimetris oedema
Reflek patella varises
3. Pemeriksaan khusus
a. Abdomen
Inspeksi membesar dengan arah memanjang
Pelebur vena linea alba linea agra strie livide
Strie albican luka bekas operasi lain-lain
Palpasi : TFU : .................cm, letak punggung :....................
Presentasi : ................................ penurun kepala : .....................................
TBJ : ...........................gram
Auskultasi : BJJ................x/mnt, reguler / irreguler
His/kontraksi : ......................

b. Ano genital
Inspeksi : pengeluaran pervagina......................condiloma : ada / tidak
Inspekulo : vagina (cairan/darah dan luka), portio : (licin/berdungkul,
cairan/darah, luka/lesi, apakah serviks sudah membuka atau belum), terdapat
jaringan plasenta/ bagian kecil janin.
Vaginal toucher : ............cm eff.........% ketuban(+/-) presentasi.................
denominator ....................... hodge ...............kesan panggul : normal / PSR /PSA

4. Pemeriksaan laboratorium :
- Laboratorium lengkap.
- USG : ...........................................

C. ANALISA
................................................................................................................................................
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D. PENATALAKSANAAN
Tanggal : ....................................................... Jam : ..........................
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Kediri,............................
Pembimbing Praktik Mahasiswa

.................................................... ......................................................
NIP. NIM.

Dosen Pembimbing

....................................................
NIP.