KEMENTERIAN KESEHATAN RI

BADAN PENGEMBANGAN DAN PEMBERDAYAAN SDM KESEHATAN

POLITEKNIK KESEHATAN MATARAM
Jalan Prabu Rangkasari Dasan Cermen Cakranegara-Mataram
Telepon (0370) 631160-621383 Faximile (0370) 621383
Website: www.poltekkesmataram.ac.id, Email:admin@poltekkesmataram.ac.id

ASUHAN KEBIDANAN KEHAMILAN PADA NY “.......”

TRIMESTER...... DENGAN .........................................
DI ...............................................................

Tanggal / waktu pengumpulan data : ................................................

Nomor register pasien : ................................................
Tempat pengumpulan data : ................................................

A. DATA SUBYEKTIF (S)

Identitas / Biodata
Nama Klien :......................... Nama Suami :.........................
Umur :......................... Umur : .........................
Suku Bangsa : ......................... Suku Bangsa : .........................
gama :......................... Agama : .........................
Pendidikan :......................... Pendidikan :.........................
Pekerjaan :......................... Pekerjaan :.........................
Alamat lengkap :......................... Alamat lengkap :.........................
Anamnesa Kebidanan
1. Tujuan/alasan kunjungan
:...........................................................................................................................
..................................................................................................................................
.......
2. Keluhan Utama
: ..........................................................................................................................
..................................................................................................................................
..................................................................................................................................
........
3. Tanda-tanda bahaya
:...........................................................................................................................
.......
4. Riwayat Sosial Ekonomi
a. Status perkawinan :...............................................................
Menikah :...............................................................
Lama :...............................................................
b. Bahasa yang digunakan di
rumah:...............................................................
c. Kebiasaan hidup sehat (merokok / penggunaan alcohol /obat –
obatan
terlarang):......................................................................................................
......................................................................................................................
d. Dukungan dari suami / keluarga mengenai kehamilannya :
......................................................................................................................
......................................................................................................................
e. Status kesehatan
suami: ..............................................................................
 f. Respon ibu dan keluarga terhadap kehamilan
:........................................... ..................................................................
....................................................
g. Kepercayaan yang berhubungan dengan kehamilan
:..............................................................................................................
.......................................
h. Hubungan seks selama kehamilan
:..............................................................................................................
.......................................
i. Pengambilan keputusan dalam keluarga : .......................................
j. Rencana tempat melahirkan dan penolong persalinan :
......................................................................................................................
......................................................................................................................
k. Persiapan persalinan
 Transportasi : ...........................
 Pendamping persalinan : ...........................
 Alat – alat dan pakaian ibu beserta bayi : ...........................
 Donor darah : ...........................
5. a. Riwayat Kesehatan / penyakit yang pernah atau sedang diderita
 Jantung :Tidak ada/Ada
 Hipertensi : Tidakada/Ada
 Diabetes Mellitus : Tidakada/Ada
 Asma : Tidakada/Ada
 Batuk berkepanjangan lebih dari 1 bulan (Tuberkolosis): Tidakada/Ada
 Penyakit Ginjal : Tidakada/Ada
 Riwayat alergi ( termasul alergi obat-obatan) : Tidakada/Ada
 Gangguan Mental (Pshycosa postpartum) : Tidakada/Ada
 Sirce cell disease : Tidakada/Ada
 Lain – lain : Tidakada/Ada
6. Riwayat penyakit menular seksual
 Riwayat diagnosis dan pengobatan seksual transmitted infection termasuk
AIDS : Tidak ada/Ada
 Pengeluaran vagina yang abnormal : Tidakada/Ada
 Luka dan pembengkakan pada vaginal : Tidakada/Ada
 Rasa nyeri pada saat berkemih : Tidakada/Ada
 Diare yang berkelanjutan lebih dari 1 bulan : Tidakada/Ada
7. Riwayat operasi
 Operasi atau luka pada pelvis : Tidakada/Ada
 Transfusi darah : Tidakada/Ada
8. Riwayat ginekologi
 Salpingectomy : Tidakada/Ada
 Pengobatan infertilitas : Tidakada/Ada
 Kehamilan ektopik : Tidakada/Ada
 Operasi pada vagina, pelvic, dan uterus : Tidakada/Ada
9. Riwayat Menstruasi
 Usia Menarche : .........Th
 Siklus menstruasi : ..........Hari
 Lama menstruasi : ..........Hari
 Jumlah darah : ........x ganti pembalut
 Rasa sakit saat menstruasi/dismenorhea : Tidak ada/Ada
10. Riwayat Kontrasepsi
 Metode yang pernah dipakai : ...........................................
  Kapan berhenti dan alasannya : ...........................................
 penggunaan kontrasepsi sebelum hamil: ...........................................
11. Riwayat kehamilan ini
a. Hamil ke : ...........................................
b. HPHT :...........................................
HTP : ...........................................
c. Umur kehamilan menurut ibu : ...........................................
d. Pergerakan fetus dirasakan pertama kali : ...........................................
Pergerakan fetus dalam 24 jam terakhir : ...........................................
e. Keluhan yang dirasakan selama kehamilan: ...........................................
f. Tanda bahaya / penyulit : Tidakada/Ada
g. Riwayat ANC : ............................................
h. Immunisasi TT :...........................................
i. Kekhawatiran – kekhawatiran khusus : ...........................................
j. Obat yang dikonsumsi/termasuk jamu : ...........................................

12. Riwayatkehamilan, persalinan dan nifas yang lalu

Ha UK RiwayatPersalinan Masalah/Penyakit Anak

mil
Tempat Penolon Jenis Hamil Partu Nifa JK BBL H/ Usia
Ke
g s s M

13. Riwayat Diet/Gizi yang dikonsumsi / makan sehari – hari : (sebelum dan
selama hamil):
 Frekuensi makan :..............................................................................
 Porsi makan : .........................................................................
 Menu/jenis makanan : .........................................................................
 Perubahan/masalah makan yang dialami(termasuk ngidam, makan
makanan non food/pica, gejala kehilangan selera makan, mual muntah,
letih, lesu, sakit gusi, kelelahan dll): ............................................................
 Frekuensi minum : .........................................................................
14. Pola eliminasi
Sebelumhamil
Frekuensi : BAB ........xsehari, BAK .........x sehari
Konsistensi : BAB ......................,BAK ......................
Kesulitan : Tidakada/Ada

SelamaHamil
Frekuensi : BAB ........xsehari, BAK .........x sehari
Konsistensi : BAB ......................,BAK ......................
Kesulitan : Tidakada/Ada
15. Beban kerja/Aktivitas sehari – hari : ..................................................................
16. Pola istirahat dan tidur
 Siang : ± ....... jam
Malam : ± ....... jam
17. Personal Hygiene
Mandi :.......... x sehari
Gosokgigi : .......... x sehari
Gantipakaian : .......... x sehari

B. Data Obyektif (O)

1. Keadaan umum
: ..................................................
2. Keadaan emosi
: ..................................................
3. Kesadaran : ..........................................
........
4. Keadaan Emosional
:..................................................
Postur tubuh :..................................................
HTP : ..................................................
UK : ..................minggu
Berat badan sekarang : ............ kg
BB sebelum kehamilan : ............ kg
Kenaikan BB selama hamil :............ kg
Tinggi badan : ............cm
Lila : ............ cm
5. Tanda – tanda vital
Tekanan darah : ................mmHg Denyut nadi : ................x/ mnt
Suhu tubuh : ................° C Pernafasan : ................x/mnt
6. Pemeriksaan Fisik
a. Kepala : Rambut..............., distribusimerata/tidak merata,
kulitkepalabersih/tidak bersih, ada/tidakadaketombe,
ada/tidakadalesidanada/tidak ada infeksi.
b. Muka :Tidakpucat/pucat , terdapat/tidak
terdapatcloasmagravidarum, tidak ada/adaoedema
c. Mata
Kelopak mata : Normal/Tidak normal
Konjungtifa : Tidakanemis/Tidak Anemis
Sklera : Tidakicterus/Tidak Ikterus

d. Mulut dan gigi

Bibir :Lembab/Kering/Sariawan
Rahang dan lidah : Merah/Pucat
Gigi dan gusi :Terdapat/tidak terdaatkaries,
gusikemerahan/pucat
e. Leher
Kelenjar thyroid :Tidakada/adapembesaran
Kelenjar getah bening/Limfe :Tidakada/adapembesaran
Bendungan vena Jugularis :Tidakada/adabendungan
f. Payudara
Areola : Hyperpigmentasi/ada
Simetris : Simetris/tidak simetris
Pembesaran : Ada/tidak
Putting susu :Menonjol / datar / tenggelam
Benjolan /Tumor/massa :Tidakada/ada
 Pengeluaran :Tidakada/ada
Rasa nyeri tekan :Tidakada/ada
g. Abdomen
Bekas luka operasi : Tidakada/ada
Linea : .........................
Striae : .........................
Kontraksi : Tidakada/tidak
Palpasi Leopold
 Leopold I :....................................................................
.....................................................................
TBBJ : ...........................................................
 Leopold II : .....................................................................
 Leopold III :.....................................................................
 Leopold IV :....................................................................
DJJ : ada, irama....................Frekuensi ......x /menit
h. Ektremitas atas dan bawah
 Oedema : Tidak ada/ada
 Kekauan sendi : Tidak ada/ada
 Kemerahan : Tidak ada/ada
 Varises : Tidak ada/ada
 Refleks patella : Normal (+/+)
7. Pemeriksaan laboratorium/ penunjang
 Hb : ............... gr%
 Prot. Urin : ...............
 Glu. Urin : ...............
C. ANALISA
1. Diagnosa
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
2. Masalah
...............................................................................................................................
...............................................................................................................................
3. Diagnosa Potensial
...............................................................................................................................
...............................................................................................................................
D. PENATALAKSANAAN(Tanggal/Waktu..............................................................)
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

Mahasiswa

( )
 Pembimbing Lahan Pembimbing Pendidikan

( ) ( )