IK-POLTEKKES-SMG-01010-03-UPM-08

ASUHAN KEBIDANAN PADA PRA NIKAH

A. PENGKAJIAN
Tanggal : …………………….................
Waktu : …………………….................
Tempat : …………………….................

B. BIODATA
Nama : Nama pasangan :
Umur : Umur :
Suku bangsa : Suku bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat : Alamat: :

C. DATA SUBYEKTIF
1. Alasan Datang
.......................................................................................................................
2. Keluhan Utama
……………...................................................................................................
3. Riwayat Obstetri
Menarch : Siklus :
Lamanya : Nyeri haid :
Banyaknya :...............................................................................................
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4. Riwayat Kesehatan
a. Penyakit/kondisi yang pernah atau sedang diderita :
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 b. Riwayat penyakit dalam Keluarga (menular maupun keturunan) :
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5. Riwayat Imunisasi : Pernah/ Tidak Pernah*)
Jenis Tanggal Keluhan Tempat
Imunisasi Pelaksanaan Pemberian
TT1
TT2
MR
Varicella

6. Rencana KB
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7. Pola Pemenuhan Kebutuhan Sehari-Hari
a. Pola Nutrisi
1) Makan
 Frekuensi makan pokok : ……….. x perhari
 Komposisi :
 Nasi : …….. x @ ……. piring (sedang / penuh)
 Lauk : …….. x @ ……. potong (sedang / besar)
jenisnya…………..................................................................
 Sayuran : …….. x @ ……… mangkuk sayur ;
jenis sayuran :.........................................................................
 Buah : …….. x sehari / seminggu;
jenis : ………………...
 Camilan : ……… x sehari;
jenis …………………………….
 Pantangan :…………………………...........................................
Alasan :………………….......................................................
2) Minum
Jumlah total .............. gelas perhari; jenis......................................
b. Pola Eliminasi
1) Buang Air Kecil
 Frekuensi perhari : …………. x warna…………………….........
 Keluhan/masalah : ………………………………………………
 2) Buang Air Besar
 Frekuensi perhari : ……x ; warna ………………………………
konsistensi lembek / keras*)
 Keluhan/masalah : ……………………………………………….
c. Pola Persnoal Hygiene
 Mandi ……… x sehari
 Keramas ……. x seminggu
 Gosok gigi …….. x sehari
 Ganti pakaian ……….. x sehari; celana dalam ……….. x sehari
d. Pola Istirahat/ Tidur
 Tidur malam …………………… jam
 Tidur siang ……………. ……….jam
 Keluhan/masalah : …………………………………………….........
e. Aktivitas Fisik dan Olahraga
 Aktivitas fisik (beban pekerjaan) …………………………………...
 Olah raga :
jenisnya………………………frekkuensi……………x……………
f. Kebiasaan yang Merugikan Kesehatan
 Merokok : ......................................................................
 Minuman beralkohol : ......................................................................
 Obat-obatan : ......................................................................
 Jamu : ......................................................................
 Sex bebas : ......................................................................
8. Riwayat Psikososial Spiritual
a. Persiapan Acara Pernikahan
 Syarat pendaftaran pernikahan...........................................................
 Penyesuaian cuti Kerja.......................................................................
 Tanggal – tanggal penting terkait pernikahan....................................
b. Persiapan Membina Rumah Tangga
 Persiapan fisik/kesehatan( medical chek up, vaksin)
 Persiapan Psikososial :
Perbedaan latar belakang budaya keluarga.........................................
Perbedaan pendidikan.........................................................................
c. Persiapan Psikologis
 Pengetahuan catin terhadap sifat pasangannya...................................
  Cara berkomunikasi dengan pasangan...............................................
 Mekanisme koping Cara mengatasi masalah......................................
d. Persiapan Spiritual
 Cara catin melakukan ibadah beserta pasangannya
............................................................................................................
e. Identifikasi Karakter
 Harapan /keinginan kebutuhan antar pasangan..................................
 Teknik manajemen konflik ................................................................
 Menanyakan kebiasaan catin .............................................................
f. Pernikahan ini diharapkan/ tidak*) oleh Nona, pasangan, dan
keluarga
g. Respon & dukungan keluarga terhadap pernikahan ini
.................................................................................................................
h. Rencana setelah menikah tinnggal dengan .............................................
i. Pengambil keputusan utama pernikahan dalam keluarga ......................
j. Orang terdekat pasien .............................................................................
k. Tingkat Pengetahuan
1) Hal – Hal yang Sudah Diketahui
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2) Hal – Hal yang Belum Diketahui
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3) Hal – Hal yang Ingin Diketahui
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D. DATA OBYEKTIF
1. Pemeriksaan Fisik
a. Pemeriksaan Umum:
1) Keadaan umum : ......................
2) Kesadaran : .................................
3) Tekanan Darah : ...................... mmHg
4) Suhu /T : ........... ⁰C
5) Nadi : ........... kali/menit
6) RR : ........... kali/menit
7) BB : ........... Kg
8) PB : ........... Cm
 9) LILA : ........... Cm
b. Status Present
Kepala :...............................................................................................
Muka :...............................................................................................
Mata :...............................................................................................
Hidung :...............................................................................................
Mulut :...............................................................................................
Telinga :...............................................................................................
Leher :...............................................................................................
Ketiak :...............................................................................................
Dada :...............................................................................................
Abdomen :...............................................................................................
Genetalia :...............................................................................................
Punggung :...............................................................................................
Anus :...............................................................................................
Ekstremitas Atas :...................................................................................
Ekstremitas Bawah :................................................................................
c. Status Obsterti
Muka : ..............................................................................................
Mammae : ..............................................................................................
Abdomen : ..............................................................................................
Genetalia : ..............................................................................................
2. Pemeriksaan penunjang
a. Pemeriksaan Darah Rutin
1) HB :
2) HbsAg :
3) Sifilis :
4) HIV/ AIDS :
5) Golongan darah :
6) Rhesus :
b. Pemeriksaan Darah yang Dianjurkan
1) Gula Darah Sewaktu (GDS) :
2) Thalasemia :
3) TORCH (TOksoplasmosis, Rubella, Citomegalovirus dan Herpes
simpleks) :
 c. Pemeriksaan Urin
Plano Tets :

E. ANALISA
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F. PENATALAKSANAAN
Tanggal : Jam :

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