PANDUAN PRAKTIK KLINIK ASUHANPRA KONSEPSI DAN KEHAMILAN

PROGRAM STUDI PROFESI BIDAN

STIKES KURNIA JAYA PERSDA PALOPO

A. DASAR PEMIKIRAN

1. Seiring dengan kemajuan dan perkembangan teknologi khususnya dibidang kesehatan, maka
dituntut peningkatan kualitas SDM bidan, sebagai pemberi pelayanan terdepan.
2. Pendidikan tenaga kebidanan mempunyai tanggung jawab untuk mempersiapkan tenaga
profesi bidan yang professional dan berjiwa nasional, tanggap terhadap perubahan dan
kemajuan Ilmu Pengetahuan Dan Teknologi (IPTEK) dan berbagai masalah dalam masyarakat
khususnya dalam lingkup praktik bidan dengan sasaran, ibu dan janin.
3. Asuhan kebidanan merupakan suatu proses yang dilaksanakan berdasarkan masalah serta
menggunakan pendekatan ilmiah dan dilandasi dengan etika profesi.
4. Dalam memberikan suatu pelayanan/asuhan yang esssensial terutama dalam meningkatkan
derajat kesehatan ibu dan anak pada khususnya dan keluarga serta masyarakat pada
umumnya diperlukan suatu keterampilan dalam memberikan asuhan pra konsepsi dan
kehamilan melalui pengkajian dalam upaya mengatasi masalah pasien ibu pra konsepsi, dan
ibu hamil.

B. DESKRIPSI PRAKTIK ASUHAN PRA KONSEPSI DAN KEHAMILAN

Mata kuliah ini memberikan kemampuan untuk melaksanakan praktik klinik pada mahasiswa dalam
memberikan asuhan kebidanan dengan pendekatan manajemen kebidanan pada kasus normal
pada ibu pra konsepsi dan ibu pada masa kehamilan.

C. TUJUAN YANG INGIN DICAPAI

1. Tujuan Umum Asuhan Kebidanan Pra Konsepsi, dan Kehamilan:
a. Untuk mendapatkan pengalaman belajar klinik dalam memberikan asuhan kebidanan pada
ibu pra konsepsi dan ibu pada masa kehamilan.
b. Memfasilitasi mahasiswa agar mampu memantau, memenuhi kebutuhan dasar manusia
baik fisik, psikososial, maupun spiritual.
 2. Tujuan Khusus
Diharapkan mahasiswa mampu:
a. Mampu melakukan pemantauan dan pendampingan dengan pengumpulan data yang
akurat, relevan secara komprehensif untuk menilai, merancang, melaksanakan dan
mengevaluasi program 1000 HPK.
b. Mampu mendesain metode dan media promosi kesehatan dan konseling untuk perencnaan
program 1000 HPK.
c. Mampu membuat keputusan klinis, melakukan replikasi program/model dalm mendukung
program 1000 HPK.
d. Mampu melakukan advokasi, yang mendukung program 1000 HPK.
e. Mampu bekerjasama dengan ibu dan keluarga dalam merancang asuhan terhadap bayi
baru lahir, bayi dan balita, dalam memenuhi hak-hak dasar anak, perlindungan anak,
menstimulasi, dan pengelolaan penyimpangan tumbuh kembangnya.
f. Mampu membangun, jejaring dan akses dalam 1000 HPK.
g. Mampu melakukan advokasi dalam rangka pemberdayaan perempuan terutama yang
mendukung partisipasi perempuan dan keluarga dalam pelayanan kesehatan bagi dirinya
serta memperjuangkan hak-hak dan nasibnya sendiri, pemenuhan hak janin sejak dalam
kandungan.
h. Mempu mempromosikan keadilan dan keseimbangan gender dalam upaya meningkatkan
status kesehatan reproduksi perempuan dan perlindungan anak.
i. Memiliki kemampuan menggunakan media atau teknologi informasi yang dapat menunjang
dalam mengakses informasi terbaru yang berfungsi dalam mendukung program 1000 HPK.
j. Memberikan asuhan kebidanan pada ibu hamil meliputi: pengkajian, perumusan diagnosa,
perencanaan, pelaksanaan, evaluasi dan dokumentasi dengan memperhatikan prinsip
patien safety dan komunikasi efektif sesuai dengan kode etik dan standar profesi pada
tatanan pelayanan kesehatansesuai dengan kewenangannya serta deteksi dini komplikasi.
k. Melakukan pencatanan dan pelaporan kebidanan
D. LANGKAH – LANGKAH PELAKSANAAN
1. Persiapan
a. Pembahasan rencana Praktik Klinik Pra Konsepsi dan Kehamilan dengan melaksanakan
rapat bersama staf kebidanan dengan pembimbing STIKES Kurnia Jaya Persada Palopo.
b. Penjajakan lapangan praktik yang dianggap presentatif untuk pelaksanaan praktek.
 2. Pelaksanaan
a. Waktu
Pelaksanaan Praktik Klinik Pra Konsepsi dan Kehamilan akan dilaksanakan selama 12
minggu.
b. Tempat Praktik
1. Puskesmas
2. BPS
E. KEGIATAN
1. Kegiatan Umum
a. Mengikuti pengarahan dari Direktur RS dan Kepala Puskesmas perkenalan dengan kepala
ruangan dan clinical instructure.
b. Orientasi pada bagian/ruangan rawat yang akan digunakan untuk pelaksanaan praktik.
c. Melapor kepada kepala ruangan tempat praktik
d. Mematuhi peraturan yang berlaku ditempat praktik.
e. Menciptakan hubungan yang baik dengan semua anggota tim kesehatan ditempat praktik.
f. Membuat laporan kegiatan harian dalam buku kegiatan harian yang ditandatangani oleh
preceptor klinik dan pembimbing institusi.
g. Membuat Asuhan kebidanan dengan menggunakan metode 7 langkah varney dan SOAP
pada kasus fisiologi ibu pra konsepsi dan ibu hamil.
h. Mengkonsultasikan kegiatan kepada preceptor klinik dan pembimbing instistusi.
2. Kegiatan Khusus
a. Dalam melaksanakan praktik klinik kebidanan pra konsepsi dan kehamilanharus tetap
menjaga privacy klien.
b. Melaksanakan praktik klinik kebidanan pada kasus yang telah dipilih meliputi bio, psikososial,
dan spiritual:
c. Pengkajian Data yaitu Pengumpulan Data:
1) Membuat riwayat kesehatan klien (ibu/bayi) dengan wawancara pada klien dan orang lain
yang dianggap penting.
2) Melakukan prosedur control infeksi:
a) Bekerja secara teknis aseptic dan antiseptic
b) Prosedur pemrosesan alat bekas pakai: dekontaminasi, pembilasan/pencucian,
desinfeksi tingkat tinggi, sterilisasi
 c) Melakukan pengkajian/ penilaian tanda-tanda vital: mengukur suhu badan, mengukur
denyut nadi, mengukur tekanan darah, menghitung pernafasan
d) Melakukan pemerikasaan fisik pada ibu hamil: inspeksi, palpasi, auskultasi, perkusi
e) Membantu melakukan pemeriksaan diagnostic: menyiapkan alat dan melakukan
pemeriksaan Hb, menyiapkan alat dan melakukan pemeriksaan urine
f) Melakukan pemeriksaan pada ibu hamil
g) Melakukan asuhan kebidanan pada ibu hamil.
3. Kegiatan Tambahan
Kegiatan ini dapat dilakukan pada kasus lain:
a. Membantu dan memberikan pelayanan kepada klien dengan melaksanakan seperti diatas.
b. Mendiskusikan dengan pembimbing yang berwenang mengenai hal-hal yang kurang jelas.
c. Mencatat sesuai kegiatan harian pada buku praktik.
d. Mengkonsultasikan semua kegiatan keterampilan dasar kebidanan pada masing-masing
pembimbing institusi.
4. Kegiatan Perseptor Klinik/Pembimbing Institusi/ Mahasiswa
1. Kegiatan Preseptor Klinik
a. Bersama mahasiswa melaksanakan asuhan kebidanan ANC.
b. Mengatur kelancaran praktik mahasiswa.
c. Mengadakan pengamatan langsung pada mahasiswa yang melaksanakan asuhan.
d. Mengecek laporan kegiatan harian mahasiswa dan kehadiran mahasiswa
e. Mengadakan diskusi dengan mahasiswa pada setiap awal minggu
f. Diskusi antara CI dan pembimbing dari institusi dalam rangka pencapaian tujuan (Respon
sehari sebelum mutasi).
g. Mengevaluasi kegiatan mahasiswa berdasarkan alat evaluasi yang telah disepakati
bersama dalam rangka pencapaian tujuan.
2. Kegiatan Pembimbing Institusi
a. Bimbingan langsung kepada mahasiswa dalam pelaksanaan praktik klinik kebidanan pra
konsepsi dan kehamilan.
b. Memeriksa laporan kegiatan harian mahasiswa yang telah diparaf oleh pembimbing
praktik klinik.
c. Memantau pencapaian target mahasiswa dalam pelaksanaan praktik klinik kebidanan pra
konsepsi dan kehamilan yang telah diparaf oleh pembimbing praktik klinik.
 d. Mengadakan komunikasi sesering mungkin dengan preceptor lahan untuk memantau
pelaksanaan praktik mahasiswa.
e. Mengevaluasi kegiatan mahasiswa berdasarkan alat evaluasi yang telah disepakati
bersama dalam rangka pencapaian tujuan.
3. Kegiatan Mahasiswa
a. Bertemu dengan pembimbing untuk orientasi.
b. Membaca kembali panduan belajar
c. Mereview materi-materi kebidanan dengan referensi terbaru dan berdasar evidence
based.
d. Menghadiri dan berpartisipasi aktif dalam pertemuan pra dan pasca klinik.
e. Melaksanakan kegiatan praktik sesuai jadwal praktik dan secara aktif berpartisipasi dalam
semua kegiatan pembimbing yang berhubungan dengan profesi bidan.
f. Mendiskusikan dengan pembimbing lahan dan institusi kasus-kasus kebidanan yang akan
diseminarkan.
g. Melaksanakan asuhan kebidanan dan keterampilan-keterampilan yang sesuai
penanganan kasus kebidanan dengan menggunakan daftar tilik.
h. Mendiskusikan dengan pembimbing hal-hal yang belum dipahami.
i. Penanganan kasus kebidanan dan keterampilan-keterampilan sesuai kasus tersebut.
j. Memastikan bahwa buku pencatatan dan format laporan telah diberi umpan balik dan
ditanda tangani oleh pembimbing.
k. Mencari dan memanfaatkan setiap kesempatan untuk lebih giat belajar
l. Mematuhi semua tata tertib Praktik Klinik.

F. EVALUASI
1. Pelaksanaan evaluasi secara terus-menerus selama mahasiswa melaksanakan kegiatan praktik
klinik pra konsepsi dan kehamilan.
2. Hal – hal yang dievaluasi:
a) Pengetahuan
b) Keterampilan
c) Sikap:
1) Disiplin dalam bertugas
2) Tanggung jawab dalam tugas
3) Kerjasama dengan orang lain sesuai dengan ketentuan institusi
 4) Inisiatif dalam bekerja
5) Komunikasi dengan klien/petugas/dan orang lain
6) Kerapihan, kejujuran, ketelitian, dan kesopanan dalam bekerja
7) Kepekaan terhadap situasi dan kondisi
3. Unsur yang menilai:
a) Preceptor Lahan
b) Pembimbing Institusi
4. Penilaian bagi mahasiswa yang belum memenuhi kehadiran praktik 100% karena mangkir,
sakit, izin, melanggar tata tertib pendidikan maka mahasiswa yang bersangkutan diharuskan
untuk mengganti ketidakhadiran sesuai dengan ketentuan:
a) Mangkir 1 hari (Alpa), pengantian dinas 3 hari.
b) Izin 1 hari, penggantian dinas 2 hari.
c) Sakit 1 hari, penggantian dinas 1 hari (harus melampirkan keterangan sakit dari dokter).

Palopo, 29 Januari 2020

STIKES Kurnia Jaya Persada Palopo
Ketua Prodi Profesi Bidan

Ira Jayanti, S.ST.,SKM.,M.Keb

Nidn. 0903038801
 TATA TERTIB PRAKTIK KLINIK ASUHAN PRA KONSEPSI DAN KEHAMILAN
PROGRAM STUDI PROFESI BIDAN
STIKES KURNIA JAYA PERSADA PALOPO

Berdasarkan hasil rapat institusi dan pihak lahan praktek bahwa dalam upaya menertibkan
pelaksanaan praktek klinik pra konsepsi dan kehamilan dipandang perlu ditetapkan tata tertib
pelaksanaannya, maka disusun tata tertib praktek klinik pra konsepsi dan kehamilanSTIKES Kurnia
Jaya Persada Palopo sebagai berikut :
A. TATA TERTIB
1. Waktu kehadiran :
a. Jam 07.30 sampai 14.00 untuk dines pagi
b. Jam 13.30 sampai 21.00 untuk dines siang
c. Jam 20.30 sampai 08.00 untuk dines malam
2. Tidak diperkenankan meninggalkan ruangan tempat praktek tanpa seizin Kepala Ruangan /
pembimbing atau petugas ruangan.
3. Sanksi Penggantian Dinas Praktek diberikan kepada mahasiswa apabila:
a. Sakit 1 kali ganti dines 1 kali
b. Izin 1 kali ganti dines 2 kali
c. Alpa 1 kali ganti dines 3 kali
4. Mahasiswi yang tidak masuk praktek sebanyak 4 kali baik dalam keterangan alpa, izin dan
sakit (tanpa keterangan surat sakit dari dokter) maka dinyatakan tidak lulus dan pembimbing
Lahan wajib memulangkan mahasiswi tersebut ke Institusi.
5. Bila mahasiswa merusak, menghilangkan alat-alat diruang praktek, mahasiswa berkewajiban
mengganti alat tersebut.
6. Mahasiswa berkewajiban menjaga kebersihan dan kelestaraian alat-alat dan bahan praktek
yang dimiliki dilahan praktek.
7. Mahasiswa hendaknya membawa sendiri alat-alat pemeriksaan fisik.
B. KETENTUAN PAKAIAN PRAKTEK
1. Pada saat melakukan praktik mahasiswa harus menggunakan pakaian praktik lengkap
dengan atribut, sepatu putih dan berpenampilan rapi dan bersih.
2. Bagi mahasiswa yang menggunakan jilbab berbis hijau.
3. Pada hari jumat mahasiswa memakai pakaian/seragam olah raga (berdasarkan ketentuan
yang berlaku di Rumah Sakit/Puskesmas).

Palopo, 29 Januari 2020

STIKES Kurnia Jaya Persada Palopo
Ketua Prodi Profesi Bidan

Ira Jayanti, S.ST.,SKM.,M.Keb

Nidn. 0903038801
 ASUHAN KEBIDANAN WANITA USIA SUBUR DALAM MASA PRAKONSEPSI
PADA NY “…………” DI
………………………………………………………………..

Tanggal Kunjungan :................................................ Jam :...........................

Tanggal Pengkajian :................................................ Jam :...........................
Nama Pengkaji :................................................

LANGKAH 1 : PENGKAJIAN DATA DASAR

A. Biodata Istri/ Suami

Nama :.................................................................................
Umur : ................................................................................
Agama :.................................................................................
Suku/Bangsa :.................................................................................
Pendidikan :.................................................................................
Pekerjaan :.................................................................................
Alamat :.................................................................................
No.HP/Telp :.................................................................................

B. Riwayat Kesehatan Sekarang

Keluhan utama :................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
C. Riwayat Pernikahan
...........................................................................................................................................
...........................................................................................................................................
D. Perencanaan Kontrasepsi
...........................................................................................................................................
...........................................................................................................................................
E. Riwayat Kesehatan Klien
...........................................................................................................................................
...........................................................................................................................................
F. Riwayat Obstetri
...........................................................................................................................................
...........................................................................................................................................
G. Riwayat Kesehatan Keluarga
...........................................................................................................................................
...........................................................................................................................................
H. Pola Fungsional Kesehatan
1. Nutrisi :.........................................................................................................
2. Pola Kebiasaan :.........................................................................................................

I. Data Psikososial
...........................................................................................................................................
...........................................................................................................................................
J. Pemeriksaan Fisik
1. Keadaan Umum :..................................................................................................
2. Tingkat kesadaran :..................................................................................................
3. Keadaan emosional :..................................................................................................
4. Tanda-tanda vital
- TD :...................... LILA :..................................
- N :...................... TB :..................................
- P :...................... BB :..................................
- S :......................
5. Kepala :......................................................................................................
6. Muka
- Oedema :......................................................................................................
7. Mata
- Conjungtiva :......................................................................................................
- Sclera :......................................................................................................
- Kotoran .......................................................................................................
:......................................................................................................
8. Mulut
- Mukosa :......................................................................................................
9. Hidung
- Polip :......................................................................................................
 10. Telinga
- Kebersihan :......................................................................................
- Gangguan pendengaran :......................................................................................
11. Leher
- Pembesaran kelenjar tyroid :...............................................................................
- Pembesaran pembuluh limfe :...............................................................................
- Peningkatan vena jugularis :...............................................................................
12. Dada
- Payudara :...........................................................................................
- Benjolan :...........................................................................................
- Areola :...........................................................................................
- Putting susu :...........................................................................................
- Nyeri tekan :...........................................................................................
- Pengeluaran cairan :...........................................................................................
13. Abdomen
- Bekas luka operasi :...........................................................................................
- Pembesaran perut :...........................................................................................
- Bentuk perut :...........................................................................................
14. Pemeriksaan Genetalia :
15. Pemeriksaan anus :...........................................................................................
16. Ekstremitas
- Oedema tangan dan jari :.................................................................
- Pucat telapak tangan dan ujung jari :.................................................................
- Oedema tibia dan kaki :.................................................................
- Betis merah/keras :.................................................................
- Varices tungkai :.................................................................
- Reflex patella kanan :.................................................................
- Reflex patella kiri :.................................................................
17. Uji Diagnostic :.................................................................

K. Pemeriksaan Penunjang :.................................................................

LANGKAH II : MERUMUSKAN DIAGNOSA/MASALAH KEBIDANAN

Diagnosa :............................................................................................................................
.............................................................................................................................

DS :............................................................................................................................
.............................................................................................................................

DO :............................................................................................................................
.............................................................................................................................

Analisa Interpretasi Data :......................................................................................................

.......................................................................................................
.......................................................................................................
LANGKAH III: MENGANTISIPASI DIAGNOSA/MASALAH POTENSIAL

Masalah Potensial :..................................................................................................................

DS :..................................................................................................................
...................................................................................................................
DO :..................................................................................................................
...................................................................................................................
Interpretasi Data :..................................................................................................................

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

LANGKAH IV : TINDAKAN EMERGENCY DAN KOLABORASI

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

LANGKAH V : RENCANA ASUHAN

Diagnosa :..................................................................................................................

Masalah Aktual :..................................................................................................................

Masalah Potensial :..................................................................................................................

Tujuan :..................................................................................................................
 ...................................................................................................................
...................................................................................................................
...................................................................................................................

Kriteria :..................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................

Tanggal :................................................ Pukul :.........................................

1. ............................................................................................................................................
Rasional :........................................................................................................................
..........................................................................................................................
2. ...........................................................................................................................................
Rasional :.........................................................................................................................
..........................................................................................................................
3. ...........................................................................................................................................
Rasional :........................................................................................................................
..........................................................................................................................
4. ...........................................................................................................................................
Rasional :.........................................................................................................................
..........................................................................................................................
5. ...........................................................................................................................................
Rasional :.........................................................................................................................
..........................................................................................................................

LANGKAH VI : IMPLEMENTASI

Diagnosa :..................................................................................................................

Masalah Aktual :..................................................................................................................

Masalah Potensial :..................................................................................................................

Tanggal :................................................ Pukul :.........................................

1. .................................................................................................................................
2. ............................................................................................................................................
3. ...........................................................................................................................................
4. ...........................................................................................................................................
5. ...........................................................................................................................................

LANGKAH VII: EVALUASI

Tanggal :................................................ Pukul :.........................................

1. .............................................................................................................................................
2. ...........................................................................................................................................
2. ...........................................................................................................................................
3. ...........................................................................................................................................
4. ...........................................................................................................................................

Palopo, April 2020

MENGETAHUI
Preseptor Lahan Preseptor Institusi

(…………………………………..)
 PENDOKUMENTASIAN ASUHAN KEBIDANAN
WANITA USIA SUBUR DALAM MASA PRAKONSEPSIPADA Ny “……..”
DI UPTD PUSKESMAS ANGKONA

A. DATA SUBJEKTIF

Identitas Istri/ Suami

Nama :.................................................................................
Umur : ................................................................................
Agama :.................................................................................
Suku/Bangsa :.................................................................................
Pendidikan :.................................................................................
Pekerjaan :.................................................................................
Alamat :.................................................................................
No.HP/Telp :.................................................................................

1. Keluhan :...................................................................................
2. Riwayat Menstruasi :...................................................................................
3. Riwayat Obstetri :...................................................................................
4. Riwayat Pernikahan :...................................................................................
5. Riwayat Kesehatan Klien :...................................................................................
6. Status TT :...................................................................................
7. Riwayat Kesehatan Keluarga :...................................................................................
8. Pola Fungsional Kesehatan
a. Nutrisi :....................................................................................................
b. Eliminasi :....................................................................................................
c. Istirahat :....................................................................................................
d. Pola Kebiasaan :....................................................................................................
e. Pola Aktifitas :....................................................................................................
f. Psikososial :....................................................................................................
g. Sexual :....................................................................................................
B. DATA OBJEKTIF

Keadaan Umum : ..............................................................................................

Kesadaran :...............................................................................................

Pemeriksaan Fisik

a. Pemeriksaan Ibu Pemeriksaan Suami

BB saat ini :............................... BB :................................................
TB :............................... TB :................................................

IMT :............................... IMT :................................................

LILA :
b. Tanda-tanda Vital

TD :...................................................................
Denyut Nadi :...................................................................
Pernapasan :...................................................................
Suhu :...................................................................

c. Wajah :...............................................................................................

d. Leher :...............................................................................................

e. Ekstrimitas
Atas :...............................................................................................
Bawah :...............................................................................................

Pemeriksaan Penunjang

a. HB :...............................................................................................
b. Gol Darah :...............................................................................................
c. HBsAg :...............................................................................................
d. HIV :...............................................................................................
e. Sifilis :...............................................................................................
C. ASSESMENT

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

D. PLANNING

Tanggal :................................................ Pukul :.........................................

1. .............................................................................................................................................
2. ...........................................................................................................................................
3. ...........................................................................................................................................
4. ...........................................................................................................................................
5. ...........................................................................................................................................

Palopo , …………... April 2020

MENGETAHUI,

Preseptor Lahan Preseptor Institusi

(………………………..……..) (……………………………….)
ASUHAN KEBIDANAN KEHAMILANPADA NY “E” DENGAN GESTASI …….….
MINGGU-…………..HARIDI
……………………………………………………………………TANGGAL ...….. BULAN
…………….TAHUN 2020

No register :.........................................................

Tgl kunjungan :......................................................... Pukul :.......................................

Tgl pengkajian :......................................................... Pukul :.......................................

Pengkaji :......................................................... ........................................

Langkah I. IDENTIFIKASI DATA DASAR

A. IdentitasIstri / Suami
Nama :........................................................................

Umur :........................................................................

Nikah / lamanya :........................................................................

Suku :........................................................................

Agama :........................................................................

Pendidikan :........................................................................

Pekerjaan :........................................................................

Alamat :........................................................................

B. Riwayat kehamilan sekarang

......................................................................................................................................
C. Riwayat kehamilan dan persalinan yang lalu
......................................................................................................................................
D. Riwayat kesehatan

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

E. Riwayat Reproduksi
 Menarche :....................................................................................................
 Lama haid :....................................................................................................
 Siklus haid :....................................................................................................
 Perlangsungan :....................................................................................................
  Dismenore :....................................................................................................
F. Riwayat KB
......................................................................................................................................
G. Riwayat Psiko Sosial Ekonomi
......................................................................................................................................
H. Pemenuhan Kebutuhan Dasar
1. Nutrisi :........................................................................................
2. Kebiasaan eliminasi :........................................................................................
3. Personal hygine :........................................................................................
4. Kebiasaan istirahat :........................................................................................
I. Pemeriksaan Fisik
1. Kepala dan rambut :.............................................................................................
2. Mata :.............................................................................................
3. Wajah :.............................................................................................
4. Hidung :.............................................................................................
5. Gigi dan mulut :.............................................................................................
6. Leher :.............................................................................................
7. Payudara :.............................................................................................
8. Abdomen :.............................................................................................
 Inspeksi :.............................................................................................
 Palpasi :.............................................................................................
- Leopold I : ............................................................................................
- Leopold II :.............................................................................................
- Leopold III :.............................................................................................
- Leopold IV :.............................................................................................
- TBJ = TFU x Lingkar perut ibu = ………= ………. gr.
 Auskultasi :.............................................................................................
9. Tungkai :.............................................................................................
J. Pemeriksaan labolatorium :
1. Hb :.............................................................................................
2. Albumin : ............................................................................................
3. Reduksi : ............................................................................................

Langkah II.IDENTIFIKASI DIAGNOSA /MASALAH AKTUAL.

Diagnosa :.........................................................................................................................
..........................................................................................................................
..........................................................................................................................
1. G…….P…….A….
DS :.........................................................................................................................

DO :

Palpasi :

- Leopold I :.............................................................................................
- Leopold II :.............................................................................................
- Leopold III :.............................................................................................
- Leopold IV :.............................................................................................
Auskultasi :....................................................................................................
Analisa dan interpretasi data:
......................................................................................................................................
......................................................................................................................................
2. Gestasi
DS :.........................................................................................................................
DO :.........................................................................................................................
Analisa dan interpretasi data:
......................................................................................................................................
......................................................................................................................................
3. Persentase kepala,punggung
DS :.........................................................................................................................
DO :.........................................................................................................................
Analisa dan interpretasi data:
......................................................................................................................................
......................................................................................................................................
4. Bergerak Dalam Panggul
DS :.........................................................................................................................
DO :.........................................................................................................................
Analisa dan interpretasi data:
......................................................................................................................................
......................................................................................................................................
 5. Intra uterin.
DS :.........................................................................................................................
DO :.........................................................................................................................
Analisa dan interpretasi data:
......................................................................................................................................
......................................................................................................................................
6. Tunggal
DS :.........................................................................................................................
DO :.........................................................................................................................
Analisa dan interpretasi data:
......................................................................................................................................
......................................................................................................................................
7. Hidup.
DS :.........................................................................................................................
DO :.........................................................................................................................
Analisa dan interpretasi data:
......................................................................................................................................
......................................................................................................................................
8. Keadaan Ibu dan janin baik.
DS :.........................................................................................................................
DO :.........................................................................................................................
Analisa dan interpretasi data:
......................................................................................................................................
......................................................................................................................................

Langkah III. IDENTIFIKASI DIAGNOSA /MASALAH POTENSIAL

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

Langkah IV. TINDAKAN EMERGENCY/KOLABORASI

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

Langkah V. INTERVENSI

Diagnosa :..................................................................................................................

Masalah Aktual :..................................................................................................................

Masalah Potensial :..................................................................................................................

Tujuan :..................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................

Kriteria :..................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................

Tanggal :................................................ Pukul :.........................................

1. ......................................................................................................................................
Rasional :........................................................................................................................
..........................................................................................................................
2. ......................................................................................................................................
Rasional :.........................................................................................................................
..........................................................................................................................
3. ......................................................................................................................................
Rasional :........................................................................................................................
..........................................................................................................................
4. ......................................................................................................................................
Rasional :.........................................................................................................................
..........................................................................................................................
5 ...........................................................................................................................................
Rasional :.........................................................................................................................
..........................................................................................................................

LANGKAH VI : IMPLEMENTASI

Diagnosa :..................................................................................................................
Masalah Aktual :..................................................................................................................

Masalah Potensial :..................................................................................................................

Tanggal :................................................ Pukul :.........................................

1. .............................................................................................................................................
2. .............................................................................................................................................
3. .............................................................................................................................................
4. .............................................................................................................................................
5. .............................................................................................................................................

LANGKAH VII: EVALUASI

Tanggal :................................................ Pukul :.........................................

1. ..........................................................................................................................
2. ..........................................................................................................................
3. ..........................................................................................................................
4. ..........................................................................................................................
5. ..........................................................................................................................

Palopo, April 2020

MENGETAHUI
Preseptor Lahan Preseptor Institusi

(…………………………………..) (…………………………………..)

PENDOKUMENTASIAN ASUHAN KEBIDANAN KEHAMILAN PADA NY “ ”

DENGAN GESTASI …….…. MINGGU-…………..HARI

DI UPTD PUSKESMAS ANGKONA

 TANGGAL ...….. BULAN …………….TAHUN 2020

No register :.........................................................

Tgl kunjungan :......................................................... Pukul :.......................................

Tgl pengkajian :......................................................... Pukul :.......................................

Pengkaji :......................................................... ........................................

A. DATA SUBJEKTIF
IdentitasIstri/ Suami

Nama :........................................................................

Umur :........................................................................

Nikah / lamanya :........................................................................

Suku :........................................................................

Agama :........................................................................

Pendidikan :........................................................................

Pekerjaan :........................................................................

Alamat :........................................................................

B. DATA OBJEKTIF

Keadaan Umum : ..............................................................................................

Kesadaran :...............................................................................................
a. Pemeriksaan Ibu
BB saat ini :...............................
TB :...............................
IMT :...............................
LILA :...............................

b. Tanda-tanda Vital
TD :...................................................................
 Denyut Nadi :...................................................................
Pernapasan :...................................................................
Suhu :...................................................................
c. Pemeriksaan Fisik :...............................................................................................

Kepala dan rambut:...............................................................................................

Mata :...............................................................................................

Wajah :...............................................................................................

Hidung :...............................................................................................

Gigi dan Mulut ................................................................................................

Leher :...............................................................................................

Payudara :...............................................................................................

Abdomen :...............................................................................................

Inspeksi :...............................................................................................

Palpasi : Leopold I...............................................................................

Leopold II.............................................................................

Leopold III............................................................................

LeopoldIV
Ekstreimitas
Atas :...............................................................................................
Bawah :...............................................................................................

C. ASSASEMENT

Diagnosa :.........................................................................................................................

..........................................................................................................................
Tanggal :................................................ Pukul :.........................................

1. ..............................................................................................................
2. ..............................................................................................................
3. ..............................................................................................................
4. ..............................................................................................................
5. ..............................................................................................................

Palopo, April 2020

MENGETAHUI
Preseptor Lahan Preseptor Institusi

(…………………………………..) (…………………………………..)