ASUHAN KEBIDANAN PADA AKSEPTOR KB

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NO. REGISTER : .........................................................................................................................

MASUK RS TANGGAL, JAM : ..................................................................................................
DIRAWAT DI RUANG : .............................................................................................................

Biodata Ibu Suami

Nama : ...........................................
Agama : ...........................................
Umur : ...........................................
Suku/Bangsa : ...........................................
Pendidikan : ...........................................
Pekerjaan : ...........................................
Alamat : ...........................................
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DATA SUBJEKTIF
1. Kunjungan saat ini Kunjungan pertama _ Kunjungan ulang _
Keluhan utama ..............................................................................................................................
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2. Riwayat Perkawinan
Kawin........ kali. Kawin pertama umur ......... tahun. Dengan suami sekarang..............tahun
3. Riwayat menstruasi
Menarche umur...........tahun. Siklus...........hari. Teratur/tidak. Lama............hari. Sifat Darah :
Encer/ Beku. Flour Albus: ya/tidak. Bau....... Dysmenorhoe : ya/tidak . Banyak Darah
........................ HPM…………………………
4. Riwayat Kehamilan
P……………Ab…………..Ah…………….
Ha Persalinan Nifas
mil Umur Jenis Komplikasi BB
Tgl lahir Penolong JK Laktasi Komplikasi
ke kehamilan Persalinan Ibu Bayi Lahir
5. Riwayat kontrasepsi yang digunakan ....................................................
Jenis Mulai memakai Berhenti/Ganti Cara
No
Kontrasepsi Tanggal Oleh tempat Keluhan Tanggal Oleh Tempat Alasan

6. Riwayat kesehatan
a. Penyakit sistemik yang pernah/sedang diderita
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b. Penyakit yang pernah/sedang diderita keluarga
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c. Riwayat penyakit ginekologi
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7. Pola pemenuhan kebutuhan sehari-hari
a. Pola Nutrisi Makan Minum
Frekuensi : ......................................kali/hari .......................................kali/hari
Macam : .................................................. .................................................
Jumlah : .................................................. .................................................
Keluhan : .................................................. .................................................
b. Pola Eliminasi BAB BAK
Frekuensi : ......................................kali/hari ......................................kali/hari
Warna : .................................................. .................................................
Bau : .................................................. .................................................
Konsisten : .................................................. .................................................
Jumlah : .................................................. .................................................
c. Pola aktivitas
Kegiatan sehari-hari : ...............................................................................................................
Istirahat/Tidur : malam................................jam. siang......................................jam
Seksualitas :Frekuensi .........................kali/minggu
Keluhan ....................................................................................................................................
 d. Personal Hygiene
Kebiasaan mandi ........ kali/hari
Kebiasaan membersihkan alat kelamin ....................................................................................
Kebiasaan mengganti pakaian dalam .......................................................................................
Jenis pakaian dalam yang digunakan .......................................................................................
8. Keadaan psikososal
a. Pengetahuan ibu tentang alat kontrasepsi
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b. Pengetahuan ibu tentang alat kontrasepsi yang dipakai sekarang
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c. Dukungan suami/ keluarga
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DATA OBJEKTIF
1. Pemeriksaan Fisik
a. Keadaan umum....................................... Kesadaran....................................................
b. Tanda Vital
Tekanan darah :...........mmHg Pernafasan : ...........kali per menit
Nadi :.........kali per menit Suhu : ...........○C
c. TB :................………….cm
d. BB : kg
e. IMT :
f. LLA : cm
g. Kepala dan leher
Hiperpigmentasi: .....................................................................................................................
Mata : ......................................................................................................................................
Mulut : .....................................................................................................................................
Leher : .....................................................................................................................................
 h. Payudara
Bentuk : ....................................................................................................................................
Putting susu : ............................................................................................................................
Massa/ tumor : ..........................................................................................................................
i. Abdomen
Bentuk : ...................................................................................................................................
Bekas luka : .............................................................................................................................
Massa/ tumor : .........................................................................................................................
j. Genetalia luar
Varices : ...................................................................................................................................
Bekas luka : ..............................................................................................................................
Pengeluaran : ...........................................................................................................................
k. Ekstremitas
Oedem : kaki kanan………….kaki kiri ……………..
Varices : kaki kanan………….kaki kiri ……………..
Refleks Patela : kaki kanan………….kaki kiri ……………..
Kuku : tangan kaki
l. Anus
Hemoroid.................................................................................................................................. :
2. Pemeriksaan dalam/ ginekologis
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3. Pemeriksaan penunjang (ditulis jam, jenis dan hasil)
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ANALISA
PENATALAKSANAAN
Tanggal …………………………….… Jam……….WIB