Lembar Pengkajian Asuhan Kebidanan Komunitas Berdasarkan Tipologi Masalah (Situasi Krisis,

Ancaman Kesehatan, dan Tidak Atau Kurang Sehat)

Asuhan kebidanan Komunitas pada Ny/Tn/Nn/An/By”.......” usia .......

Dengan.......................................................................

I. Pengkajian Data
Tanggal :
Jam :
Tempat :

A. Data subyektif
1. Biodata
Nama KK :
Jenis kelamin :
Umur :

Nama ibu : Nama suami :

Usia : Usia :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Penghasilan: Penghasilan :
Alamat : Alamat :

Nama Anak :
Jenis Kelamin :
Anak Ke :
Usia :
Agama :
Pendidikan :
Pekerjaan :
Status :
2. Keluhan
…………………………………………………………………………………………………
…………………………………………………………………………………………………
………………………………………………………………………………………..............
3. Riwayat kesehatan yang lalu
…………………………………………………………………………………………………
…………………………………………………………………………………………………
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4. Riwayat kesehatan sekarang
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………............……..
5. Riwayat kesehatan keluarga
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………..........………
6. Riwayat menstruasi
a. Menarche :……………………………..tahun
b. Siklus haid :…………………………….hari
c. Lama :……………………………. hari
d. Jumlah :…………………………….x/softex
e. Keluhan :……………………………..
f. HPHT :……………………………..
g. HPL :…………………………….
h. Lochea : ..........................................
7. Riwayat perkawinan
a. Status perkawinan :………………………..
b. Menikah :……………………….kali
c. Lama pernikahan :……………………….tahun
 8. Riwayat kehamilan, persalinan dan nifas yang lalu

Masa
Kehamilan Persalinan Anak Nifas
lah
No
Hamil
Jenis Penolong Cara Penyakit Sex BB/PB H/M Umur Hari ASI
ke

9. Riwayat kehamilan sekarang

Trimester I (Jumlah Kunjungan, Keluhan, Terapi) :

…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………..............……………………………

Trimester II (Jumlah Kunjungan, Keluhan,Terapi) :

…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
……………………………………………………………............................................……………

Trimester III(Jumlah Kunjungan, Keluhan, Terapi)

…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………..............................................……………..

10. Riwayat KB

a. Jenis :………………………………...

b. Lama :…………………………………
c. Keluhan :…………………………………

11. Pola kebiasaan sehari-hari

No. Pola Kebiasaan Keterangan

1 Nutrisi

2 Istirahat

3 Eliminasi

4 Aktivitas

5 Personal hygiene

6 Kebersihan lingkungan

7 Merokok
 8 Dan lain-lain

12. Riwayat Psikologi, sosial budaya dan spiritual

a. Psikologi

………………………………………………………………………………………………………
………………………………………………………………………………………………………

b. Sosial Budaya

………………………………………………………………………………………………………
………………………………………………………………………………………………………

c. Spiritual

………………………………………………………………………………………………………
……………………………………………………………………………………………………....

B. Data Objektif
1. Pemeriksaan Umum
a. Keadaan Umum :……………………………………………
b. Kesadaran :................................................................
c. Tekanan Darah :…………………………………………….MmHg
d. Nadi :…………………………………………….x/menit
e. Suhu :…………………………………………….0c
f. RR :……………………………………………x/menit
g. Berat badan :…………………………………………….Kg
h. Tinggi Badan :…………………………………………….Cm
i. LK :…………………………………………….Cm
j. LD :................................................................Cm
 k. LP :.................................................................Cm
l. Lila :.................................................................Cm
2. Pemeriksaan Fisik
a. Inspeksi
a) Rambut :…………………………………………………………....……………
..........................................................................................................
b) Muka : ..................……………………………………………………………..
...........................................................................................................
c) Mata : ………………………………………………………………………….
...........................................................................................................
d) Telinga : ……………………………………………………………………........
..........................................................................................................
e) Hidung :………………………………………………………………...............
...........................................................................................................
f) Mulut dan gig :…………………………………………………........................
................................................................................................
g) Leher :……………………………………...................……………….
...................................................................................................
h) Dada :…………………………………………………………………..

i) Genetalia :…………………………………………………………………
................................................................................................
j) Ekstermitas Atas:………………………………………………………………..
................................................................................................
k) Ekstremitas bawah:………………………………………………………………
...................................................................................................
b. Palpasi
a) Kepala :………………………………………………………………….
................................................................................................
b) Leher :……………….......……………………………………………..
................................................................................................

c) Payudara :………………………………............…………………………
................................................................................................
 d) Abdomen :…………………………………………………………………..
1. Leopold I :………………………………………………………...
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2. Leopold II :……………………………............................................
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3. Leopold III :…………………………………………………………
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4. Leopold IV :………………………………………………………....
....................................................................................
5. TBJ : ……………………………….....…………………….
e) Ekstermitas atas:………………………...………………………………
f) Ekstermitas bawah :……………..…………………………………………..
c. Auskultasi
a) Dada :………………………………………………………..
b) Abdomen :………………………………………………………..
d. Perkusi
a) Abdomen :…………………………………………………………
b) Reflek patella :……………...…………………………………………

3. Pemeriksaan panggul
…………………………………………………………………………………………………
............................................................................................................................................
...........................................................................................................................................
4. Pemeriksaan Penunjang
..........................................................................................................................................
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II. Identifikasi Diagnosa Dan Masalah

Diagnosa : ..........................................................................................................
Data Subjektif : ..........................................................................................................
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Data Objektif : ..........................................................................................................
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Masalah :............................................................................................................
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III. Identifikasi Diagnosa dan Masalah Potensial

Diagnosa :............................................................................................................
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Masalah potensial : ..........................................................................................................
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IV. Identifikasi Kebutuhan Segera

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V.Intervensi
Tanggal :
Jam :
Diagnosa : ...............................................................................................................
Tujuan : ................................................................................................................
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Kriteria hasil : ...............................................................................................................
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VI. Implementasi
Tanggal :
Jam :
Diagnosa : ........................................................................................................................
Implementasi : .......................................................................................................................
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VII. Evaluasi
Tanggal :
Jam :
Diagnosa : ...........................................................................................................................

S : ...........................................................................................................................
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O : .............................................................................................................................
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 A : ............................................................................................................................
P : .............................................................................................................................
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I : ...........................................................................................................................
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E : ...........................................................................................................................
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R : ..............................................................................................................................
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N Kriteria Nilai Bobot

 o
1. Sifat masalah - 1
 Ancaman kesehatan 2
 Tidak atau kurang sehat 3
 Situasi krisis 1

2. Kemungkinan masalah untuk diubah - 2

 Dengan mudah 2
 Hanya sebagian 1
 Tidak dapat 0

3. Potensi masalah untuk diubah - 1

 Tinggi 3
 Cukup 2
 Rendah 1

4. Menonjolnya masalah 1
 Masalah berat harus segera ditangani 2
 Masalah tidak harus ditangani 1
 Masalah dapat dirasakan 0

Scoring :

a. Tentukan score setiap kriteria

b. Score dibagi dengan angka tertinggi dan dikalikan dengan bobot
c. Jumlah score untuk semua kriteria

Kelompok 4
Nama Anggota Kolompok :
1. Aleksandrina
2. Clara Labiyen
3. Siska Salatutin
4. Lusinta Rande
5. Yulianti Cresensiana Jogo
6. Maria Herlina Tiha
7. Krista Gorosa Mete Mala
8. Nurlaila
9. Mariani Indri Putri Rambu Pehi