ASUHAN KEBIDANAN PADA IBU HAMIL FISIOLOGIS TRIMESTER ...

Ny. ... UMUR ......... G... P... A... UMUR KEHAMILAN .......................
DI..........................................................................

I. PENGKAJIAN
Hari/ Tanggal : .....................................
Jam : .....................................
No.Register : .....................................

A. IDENTITAS

KLIEN SUAMI
Nama Ibu : .................................. ...................................
Umur : …………………….. ……………………...
Suku Bangsa : …………………….. ……………………...
Agama : .................................. ...................................
Pendidikan : .................................. ...................................
Pekerjaan : .................................. ...................................
Alamat : .................................. ...................................

B. SUBJEKTIF

1. Alasan Datang :
...........................................................................................................................
2. Keluhan Utama :
...........................................................................................................................
3. Riwayat Menstruasi
Menarche umur : ..........................................................................................
Siklus : ..........................................................................................
Lama : ..........................................................................................
Volume : ..........................................................................................
Konsistensi : ...........................................................................................
Warna darah : ...........................................................................................
Keluhan (fluor albus, dismenorea) :
……………………………………………………...........................................
4. Riwayat Kehamilan Sekarang
HPHT : ………………………
G P A : ………………………

a. Kehamilan Trimester I
Tanggal PP Test : ………………………
Hasil : ………………………
Dilakukan oleh : ....................................
Keluhan : ....................................
Penggunaan obat- obatan dan jamu- jamuan: ...................................
b. Kehamilan Trimester II
Frekuensi pemeriksaan : ...................................
Mulainya gerakan janin : ...................................
Keluhan yang dirasakan : ...................................
Imunisasi TT : ...................................
c. Kehamilan Trimester III
Frekuensi pemeriksaan : ...................................
Pergerakan janin dalam 12 jam terakhir : ...................................
Keluhan yang dirasakan : ...................................

5. Riwayat Kehamilan, Persalinan dan Nifas yang lalu

N Kehamilan Persalinan Nifas Ket (anak
Jenis

Penolong

Jk

BB

PB

Masalah

Lochea

laktasi

Masalah

o hidup/mati,
usia anak skrg

6. Riwayat Kesehatan
a. Dahulu
……………………………………………………………………………
b. Sekarang
 ……………………………………………………………………………
c. Keluarga
……………………………………………………………………………
d. Penyakit reproduksi
……………………………………………………………………………
7. Riwayat Perkawinan
a. Usia menikah : …………………………………………………......
b. Status Pernikahan : ..................................................................................
c. Pernikahan ke : ..................................................................................
d. Lama pernikahan : ..................................................................................

8. Riwayat Kontrasepsi yang digunakan

No Jenis Pertama Menggunakan Terakhir Menggunakan
Kontrasepsi Tanggal Oleh Tempat Keluhan Tanggal Oleh Tempat Alasan

9. Pola Pemenuhan Kebutuhan Sehari-hari

a. Nutrisi
Sebelum Hamil
Makan : ..................................................................................................................... Minum:
.....................................................................................................................
Keluhan :
.....................................................................................................................
Selama Hamil
Makan :
.....................................................................................................................
Minum :
.....................................................................................................................
Keluhan :
.....................................................................................................................
Pantangan :
.....................................................................................................................
b. Pola Eliminasi
Sebelum Hamil
BAB :
.....................................................................................................................
BAK :
.....................................................................................................................
Keluhan :
.....................................................................................................................
Selama Hamil
BAB :
.....................................................................................................................
BAK :
.....................................................................................................................
Keluhan :
.....................................................................................................................
c. Aktivitas sehari-hari
1). Pola istirahat dan tidur
Sebelum hamil :
………………………………………………………………….……
Keluhan :
...............................................................................................................
Selama hamil :
...............................................................................................................
Keluhan :
...............................................................................................................
2). Seksualitas
Sebelum hamil :
...............................................................................................................
Keluhan :
...............................................................................................................
Selama hamil :
...............................................................................................................
Keluhan :
...............................................................................................................
3) Pekerjaan
Sebelum hamil :
...............................................................................................................
Selama hamil :
...............................................................................................................
Keluhan :
...............................................................................................................
4). Personal Hygiene
Sebelum hamil :
...............................................................................................................
Selama hamil :
...............................................................................................................
9. Riwayat Psikososial dan budaya
a. Apakah kehamilan ini direncanakan/ diinginkan :
.....................................................................................................................
b. Kepercayaan yang berhubungan dengan kehamilan :
…………………………………………………………………………….
c. Hubungan ibu dengan orang lain
…………………………………………………………………………….
c. Pengambil keputusan : …………………………………………………...
d. Rencana bersalin di : ……………………………………………...........
e. Jarak rumah dengan tempat bersalin : .......................................................
11. Pengetahuan Ibu tentang ANC ( Ante Natal Care )
a. Tablet Fe
.....................................................................................................................
b. Gizi selama hamil
……………………………………………………………………….........
d. Perawatan Payudara
.....................................................................................................................
e. Tanda- bahaya kehamilan
.....................................................................................................................
f. Seksualitas dalam kehamilan
.....................................................................................................................
g. Kebiasaan yang merugikan Ibu dan Janin
.....................................................................................................................

C. DATA OBJEKTIF
1. Pemeriksaan Umum
a. Keadaan umum : …………………………
Kesadaran : …………………………
Status emosional : …………………………
b. BB sekarang : ………………………....
Sebelum hamil : ........................................
Kenaikan BB : ........................................
TB : ........................................
Lila : ........................................
c. Tanda-Tanda Vital
Tekanan darah : ........................................
Denyut nadi : ........................................
 Pernafasan : ........................................
Suhu : …………………………

2. Pemeriksaan Fisik
a. Kepala dan Leher
Kepala : …………………………………………………………............
Muka : ....................................................................................................
Alis mata : …………………………………………………………............
Mata : …………………………………………………………............
Konjungtiva : ....................................................................................................
Sklera : ....................................................................................................
Mulut dan Gigi
Mulut : …………………………………………………………............
Gusi : …………………………………………………………............
Gigi : …………………………………………………………............
Bibir : …………………………………………………………………
Telinga : …………………………………………………………............
Hidung : …………………………………………………………………
Leher
Kelenjar Limfe : ……………………………………………………...........
Kelenjar tyroid : ……………………………………………………...........
Vena jugularis : …………………………………………………………...
b. Dada
Bentuk : …………………………………………………………...
Jantung : …………………………………………………………...
Paru-paru : ...........................................................................................
c. Payudara
Putting susu : ……………………………………………………….......
Bentuk : …………………………………………………………...
Benjolan : …………………………………………………………...
Rasa nyeri : ...........................................................................................
d. Ketiak
Kelenjar limfe : ……………………………………………...........
e. Abdomen
 Bekas luka operasi : …………………………………………………...
Hepatomegali : ...............................................................................
Splenomegali : ...............................................................................
f. Pinggang dan punggung
Nyeri ketuk pinggang : ...............................................................................
Posisi punggung : ...............................................................................
g. Genetalia luar
Varises : ……………………………………………………...........
Luka parut : ……………………………………………………….......
Oedema : …………………………………………………………...
Flour albus : …………………………………………………………...
h. Anus : ……………………………………………………….......
i. Ekstremitas
Ekstremitas atas :
Telapak tangan : …………………………………………………………...
Kuku : …………………………………………………………...
Kapiler refill : ……………………………………………………...........
Oedema : ……………………………………………………...........
Varises : ...........................................................................................
Ekstremitas bawah
Telapak kaki : ...........................................................................................
Kuku : ...........................................................................................
Kapiler refill : ...........................................................................................
Oedema : ...........................................................................................
Varises : ...........................................................................................
Refleks patella : ...........................................................................................
3. Pemeriksaan obstetrik
c. Inspeksi
Payudara : ……………………………………………………….......
Abdomen : ……………………………………………………….......
Genetalia : ...........................................................................................
b. Palpasi
Payudara : ...........................................................................................
Abdomen : ...........................................................................................
Leopold I :
.................................................................................................................................
Leopold II :
……………………………………………………………………………………
Leopold III :
……………………………………………………………………………………
Leopold IV :
……………………………………………………………………………………
Palpasi luar : ..........................................................................................
Panjang uterus menurut Mc. Donald : ………………………..............................
TBJ : ……………………………………………………..........
c. Auskultasi
DJJ : ...........................................................................................
d. Ukuran panggul luar
Distansia spinarum : …………………………………………………………...
Distsnsis kristarum : ……………………………………………………….......
Konjugata eksterna : …………………………………………………………...
Lingkar panggul : …………………………………………………………...
e. Ukuran panggul dalam:
Promontorium :
Lengkung sacrum :
Linea innominata :
Dinding samping pelvis :
Spina ischiadicas :
Arcus pubis :
Mobilitas os coxygis :
f. Pemeriksaan Penunjang
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II. INTERPRETASI DATA

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III. DIAGNOSA POTENSIAL
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IV. TINDAKAN SEGERA
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V. PERENCANAAN TINDAKAN
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VI. PELAKSANAAN
Hari/ Tanggal :
Jam :
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VII. EVALUASI
Hari/ Tanggal :
Jam :
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