KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENKES MALANG

JURUSAN KEBIDANAN
HIMPUNAN MAHASISWA PRODI
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 Perinatalogi

I. Pengkajian
II. DATA SUBYEKTIF
Biodata
Nama :

Umur :

Kelamin :

Agama :

Nama ayah :

No reg :

Ruangan :

Tanggal MRS :

Tanggal KRS :

Diagnosis Medis :

Cara masuk :

Datang Sendiri Rujukan dari :

Diagnose :

1. Keluhan utama :
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2. Riwayat penyakit sekarang :
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3. Jenis persalinan :
4. APGAR Score :
5. Berat Badan :
6. Panjang Badan :
7. Usia Kehamilan :
8. Ketuban
Pecah dini jam : ......................... jelas ............... warna :jernih, keruh, meconeal
Tidak pecah dini
Lain lain
9. Riwayat ketuban dan kelahiran :
Antenatal : dokter / bidan / puskesmas / RS / dll
Berapa kali : ..................
Dokter Bidan Puskesmas
Rumah Sakit Lain-lain
NATAL :
10. Post Natal :
11. Imunisasi :
12. Riwayat kesehatan keluarga : Contreng di kolom yang sesuai
YA TIDAK YA TIDAK Sebutkan

DM HIPERTENSI Lain-lain

TBC HEPATITIS Lain-lain

A. DATA OBYEKTIF
1. Pemeriksaan fisik

a. Keadaan umum : cukup / baik/ lemah

Suhu :suhu aksilar.....°C

Nadi : ....................x/menit
Pernafasan : ....................x/menit
Berat badan : ....................gram
Panjang badan : ....................cm
Lingkar kepala : ....................cm
Lingkar lengan : ....................cm
Lingkar perut : ....................cm
Lingkar dada : ....................cm

b. Kesadaran
( ) Gerak aktif ( ) Menangis Kuat ( )Lethargi ( ) Merintih
( ) Koma ( ) lain-lain
c. Kepala
I. Rambut
Tipis Ya/tidak kering Ya/tidak
Kotor Ya/tidak Jarang Ya/tidak
II. Mata
Konjungtiva Anemis Ya/tidak Merah Ya/tidak
Sklera Ikterus Ya/tidak Lain-lain Ya/tidak
III. Wajah
Ikterus Ya/tidak Geimace Ya/tidak
Pucat Ya/tidak Cyanosis Ya/tidak
Lain-lain
IV. Telinga
Simetris Ya/tidal Radang Ya/tidak
Sekret Ada/tidak Perdarahan Ya/tidak
Tulang rawan +/- lain-lain............
V. Hidung
Pernafasan cuping hidung Ya/tidak
Lain-lain.........................
VI. Mulut
Bibir kering Ya/tidak Trismus Ya/tidak
 Lidah kotor Ya/tidak Lain-lain............................
VII. Leher
Pembesaran Ada/tidak Kaku kuduk Ada/tidak
d. Thorak
Gerak Nafas : relaksi otot dada normal/tidak
Bentuk : Normal chest Barel chest
Irama nafas : reguler Irreguler
Stridor
Payudara : Ronchi Ada/tidak Whezing Ada/tidak

Jantung : Reguler Irreguler

Murmur Irama galop
e. Abdomen
Inspeksi : Bentuk : buncit/ tegang/ normal
Acites : ada/tidak
Tali pusar : ....................................
Palpasi : Massa : Ada/tidak
Fecalit : Ada/tidak
Distensi : Ada/tidak
Pembesaran Hepar : Ada/tidak
Perkusi : Thyampany Hypertimpany
Dulnes Lain-lain.................
Auskultasi : Peristaltik usus................ x/menit
f. Genetali
Labia : Oedem : Ya/tidak
Perdarahan : Ya/tidak
Labia Mayor menutupi labia minor : ya/tidak
Scrotum : Oedem : Ya/tidak
Sudah turun : Ya/Tidak
g. Anus
Berlubang : Ya/tidak
Pendarahan : Ya/tidak
Lain-lain :.............
h. Extermitas
Atas : Polidactili Ya/tidak
Syndaktili Ya/tidak
Gerak aktif Ya/tidak
Fratur Ya/tidak
Bawah : Polidactili Ya/tidak
Syndaktili Ya/tidak
CTEV Ya/tidak
Genovalgus Ya/tidak
i. Neurologi
YA TIDAK YA TIDAK

KAKU KEJANG
KUDUK
MUNTAH PANAS

j. Reflek Bayi
Rooting Ya/tidak
Sucking Ya/tidak
 Moro Ya/tidak
Babynski Ya/tidak
Grappe Ya/tidak
Swallowing Ya/tidak
2. Pemeriksaan Penunjang
Laborat :
Foto :
Lain-lain :

B. ANALISIS / INTEPRETASI DATA

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

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NIP. NIM.
NIP. NI
Dosen Pembimbing

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NIP.