ASUHAN KEBIDANAN PADA IBU HAMIL

..........................................................
.................................................

No RM :………………………………..
Masuk tgl/jam :………………………………..
Tempat :………………………………..
Pengkajian Tgl/jam : ...........................................

SUBYEKTIF
1. Identitas Istri Suami
Nama :............................. .......................................
Umur :.............................. .......................................
Agama :.............................. .......................................
Pendidikan :.............................. .......................................
Pekerjaan :.............................. .......................................
Suku/bangsa :.............................. .......................................
Alamat :.............................. .......................................
Telp :.............................. .......................................

2. Alasan datang/keluhan
..............................................................................................................................................................................
3. Riwayat Haid
Menarche :.....................................................................................................
Lama :.....................................................................................................
Siklus :.....................................................................................................
Teratur/tidak :.....................................................................................................
Banyaknya ganti pembalut : ....................................................................................................
Keluhan : ....................................................................................................
4. Riwayat Perkawinan
Perkawinan ke : ....................................................................................................
Status : ....................................................................................................
menikah sejak umur : ....................................................................................................
 lama perkawinan : ....................................................................................................

5. Riwayat Obstetric
Jenis BB
no Th penolong tempat UK J/K komplikasi Ket
Persalinan lahir

6. Riwayat KB
PASANG LEPAS
NO
metode Tgl petugas tempat Tgl petugas tempat Alasan

7. Riwayat Kesehatan
a. Riwayat Kesehatan Sekarang
b. Riwayat Kesehatan Yang Lalu
c. Riwayat Kesehatan Keluarga

8. Riwayat Kehamilan Sekarang

HPHT .................................................................................................................................................................
Umur kehamilan ...............................................................HPL.................................................................
Gerakan pertama kali dirasakan pada umur kehamilan..............................................................
Gerakan dalam satu hari.............................................................................................................................
Status imunisasi TT:..............................Imunisasi TT terakhir: ..................................(bln/th)
Keterangan
Tekanan Hasil - Tempat Kapan
Keluhan Berat UK Tinggi Letak Kaki Nasihat yg
Tgl Darah DJJ px Therapy Pelayanan Harus
Sekarang Badan (minggu) Fundus Janin Bengkak disampaikan - Nama Pemeriksa
(mmHg) lab Kembali
(Paraf)
9. Pola Kebutuhan Sehari-hari (selama hamil)
a. Nutrisi
Porsi makan sehari :.........................................................................................................
Jenis :.........................................................................................................
Makanan pantang :.........................................................................................................
Pola minum :.........................................................................................................
Masalah :.........................................................................................................
b. Eliminasi
1) BAK
Frekuensi ......................jumlah.......................warna...................................................................
Keluhan................................................................................................................................................
2) BAB
Frekuensi ......................,jumlah.......................warna..................................................................
Keluhan................................................................................................................................................
c. Istirahat
Siang.............................................................malam......................................................................................
Keluhan...........................................................................................................................................................
d. Aktivitas :............................................................................................................................
e. Personal higiene
Mandi :............................................................................................................................
Keramas :............................................................................................................... ............
Potong kuku :............................................................................................................... ............
Ganti baju :............................................................................................................... ............
Ganti celana dalam :............................................................................................................... ............
f. Pola seksual
Frekuensi : ...........................................................................................................................
Keluhan : ...........................................................................................................................
10. Data Psikososial Spiritual
Tanggapan ibu dan keluarga terhadap kehamilan ini :.............................................................
Pengambilan keputusan oleh :.............................................................
Ketaatan ibu beribadah :............................................................
Ibu tinggal bersama :............................................................
Hewan piaraan :............................................................
Rencana melahirkan di :............................................................

OBYEKTIF
1. Pemeriksaan umum
KU :............................................................................................
Kesadaran :............................................................................................
TB :............................................................................................
BB : ...........................................................................................
LILA :............................................................................................
Vital sign :T :...............................N :….............................................
S :...............................P :................................................
2. Pemeriksaan fisik
Kepala :............................................................................................................
Muka :............................................................................................................
Mata ;............................................................................................................
Leher :............................................................................................................
Aksila :............................................................................................................
Ekstremitas atas (kanan & kiri) :............................................................................................................
Payudara :............................................................................................................
Abdomen :
Inspeksi :............................................................................................................
PalpasiLeopold :
LI :............................................................................................................
LII :............................................................................................................
LIII :............................................................................................................
LIV :............................................................................................................
TFU menurut McDonald :…….………………………………………………………………………..
 TBJ :............................................................................................................
DJJ :........... kali/menit Teratur/ tidak
Punctum max : ...........................................................................
Genetalia :..............................................(inspekulo bila dilakukan)
Ektremitas bawah (ka & ki) :...............................................(reflek patela kanan/kiri)

3. Pemeriksaan Penunjang
a. PP tes : ..........................tgl............................
b. urine : ...........................tgl.............................(PP test, Protein, Glukosa, dll)
c. darah : ...........................tgl..........................(Hb, Al, HMT, Golongan darah)
d. USG, dll
ASSESMENT

PENATALAKSANAAN
Tanggal: Jam: