FORMAT ASUHAN KEBIDANAN KEHAMILAN NORMAL

Makalah Disusun Guna Memenuhi Tugas Dokumentasi Kebidanan

Dosen Pengampu : Winarni, S. SiT.

Disusun Oleh :

ANGKATAN TAHUN 2015

PRODI D-III KEBIDANAN

STIKES ‘AISYIYAH SURAKARTA
2015
 ASUHAN KEBIDANAN PADA IBU HAMIL PADA Ny.....Umur.....
Dengan.........
Tanggal masuk : .........................................................................................
Jam : .........................................................................................
Tempat : .........................................................................................
No. Register : .........................................................................................

I. PENGUMPULAN DATA
Tanggal : ..................................................................................................
Jam : ..................................................................................................
Oleh : ..................................................................................................

A Data Subjektif
1 Identitas
Istri Suami
Nama : .............................. .................................
Umur : .............................. .................................
Suku/Bangsa : .............................. .................................
Agama : .............................. .................................
Pendidikan : .............................. .................................
Penghasilan : .............................. ...................................
Pekerjaan : .............................. ..................................
Alamat : .............................. ..................................

2 Alasan Kunjungan : ......................................................................

3 Riwayat Kebidanan
a. Riwayat Menstruasi
Menarche : ........................................................................
Sifat darah : ........................................................................
Siklus : ........................................................................
Lama : ........................................................................
Warna : ........................................................................
Bau : ........................................................................
Dismenorrhea : ........................................................................
Fluor albus : ........................................................................
HPHT : ........................................................................
HPL : ........................................................................
b. Riwayat Pernikahan
Usia saat menikah : .....................................................
Lama pernikahan : .....................................................
Status pernikahan : ....................................................
 c. Riwayat kontrasepsi
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d. Riwayat kehamilan, persalinan dan nifas yang lalu
Anak

PERSALINAN NIFAS
TGL LAHIR

Laktasi

Komplikasi
BB Lahir

Perdarahan
N Umur
Penolong

o Jenis Komplikasi
Kehami

JK
lan
persali
nan
Ibu Bayi
1.
2.
3.

e. Riwayat kehamilan sekarang

G....P.....A..... Umur kehamilan .........................
TM I :
ANC ke- dan tempat : ..............................................................
Keluhan : ..............................................................
Tindakan : ..............................................................

TM II :
ANC ke- dan tempat : ..............................................................
Keluhan : ..............................................................
Tindakan : ..............................................................

TM III :
ANC ke- dan tempat : ..............................................................
Keluhan : ..............................................................
Tindakan : ..............................................................

4 Riwayat Kesehatan
a. Riwayat kesehatan ibu yang lalu
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b. Riwayat kesehatan ibu sekarang
........................................................................................................
c. Riwayat kesehatan keluarga
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.......................................................................................................
d. Riwayat keturunan kembar
........................................................................................................

e. Pola Fungsional
a. Pola Makan
Kebiasaan makan minum : .....................................................
b. Pola Aktivitas
Kebiasaan aktivitas : .....................................................
c. Pola istirahat
Kebiasaan istirahat : .....................................................
d. Pola Eliminasi
Kebiasaan BAK dan BAB : ....................................................
e. Pola Kebersihan
Kebiasaan mandi dan hygiene: ...................................................
f. Pola seksual
Kebiasaan seksual : .....................................................

f. Data psikologi, sosial budaya dan spiritual

1) Psikologi
a. Jenis kelamin anak yang diharapkan : ..................................
b. Dukungan suami : .................................................................
c. Dukungan keluarga : .............................................................

2) Sosial budaya
a. Dukungan lingkungan sekitar : ...............................................
b. Hubungan dengan lingkungan sekitar : .................................

3) Spiritual
a. Pola ibadah ibu : .....................................................................
b. Tindakan ibu untuk persiapan persalinan : ............................
.................................................................................................
B Data Objektif
1. Keadaan Umum : .....................................................................
2. Kesadaran : .....................................................................
3. Tinggi badan : .....................................................................
4. Berat badan
Sebelum hamil : ...................................................
Saat hamil : ...................................................
Kenaikan BB : ...................................................
LILA : ...................................................

5. Tanda-tanda Vital
TD : ......................... mmHg
Pernapasan : ......................... x/menit
Nadi : ......................... x/menit
Suhu : ......................... OC
6. HPHT : ....................... HPL : ....................... UK :....................
7. Pemeriksaan fisik
a Kepala
Rambut dan kulit kepala : ..................................................
Muka : ..................................................
Mata : ..................................................
Hidung : ..................................................
Mulut : ..................................................
Telinga : ..................................................
Leher : ..................................................
b Dada : ..................................................

c Payudara : ..................................................
d Ketiak : ..................................................
e Abdomen
Palpasi Leopold I : ..................................................
Palpasi Leopold II : ..................................................
Palpasi Leopold III : ..................................................
Palpasi Leopold IV : ..................................................
TFU : ..................................................
TBJ : ..................................................
Auskultasi puctum max. : ..................................................
DJJ : ..................................................
Gerakan Janin : ..................................................
f Punggung dan pinggang : ..................................................
 g Genetalia
1. Vulva
Oedema : ....................................................
Varises : ....................................................
Pengeluaran pervaginam : ....................................................
Luka : …................................................
2. Anus : ....................................................
h Ekstermitas
Atas : ......................................................................................
Bawah : ......................................................................................

II. INTERPRETASI DATA

Ny.................... umur ......... tahun G ... P ... A ... hamil.......... minggu.
Dasar : S : ................................................................................................
HPHT :.....................................................................................
HPL :........................................................................................
O : KU : ...................................
VS : T : ................ mmHg S : ................... 0C
N : ............... x/menit R : .................. x/menit
Palpasi Leopold I : ..................................................
Palpasi Leopold II : ..................................................
Palpasi Leopold III : ..................................................
Palpasi Leopold IV : ..................................................
TFU : ..................................................
TBJ : ..................................................
DJJ : ..................................................
Gerakan Janin : ..................................................

Masalah :
Kebutuhan :

III. DIAGNOSA POTENSIAL

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IV.ANTISIPASI
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V.RENCANA TINDAKAN
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VI.IMPLEMENTASI
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VII.EVALUASI
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