POLITEKNIK KESEHATAN KEMENKES TERNATE

PROGRAM DIPLOMA III KEBIDANAN

Nama Kelompok :

NIM :

Tempat Praktik :

ASUHAN KEBIDANAN PADA IBU HAMIL

Tanggal Masuk : ....................................
No. Register : ....................................

I. PENGKAJIAN

A. IDENTITAS (Biodata) :
Nama Pasien : ............................. Nama Suami : ...............................
Umur : ............................. Umur : ................................
Suku/Bangsa : ............................. Suku/Bangsa : ...............................
Agama : ............................. Agama : ................................
Pendidikan : ............................. Pendidikan : ................................
Pekerjaan : ............................. Pekerjaan : ................................
Penghasilan : ............................. Penghasilan : .................................
Alamat Rumah : .............................. Alamat Rumah : ................................
Alamat Kantor : ............................. Alamat Kantor : ................................
Telp. ..................... Telp. ......................

B. ANAMNESA (Data Subyektif ) Pada tanggal : ................................, Pukul : ......................

Kunjungan Saat ini : Kunjungan Pertama Kunjungan Ulang

1. Keluhan utama pada waktu masuk :

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 2. Riwayat Penyakit Sekarang :
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3. Riwayat Menstruasi :
a. Haid Pertama / Menarche : Umur ............................., Tahun ......................
b. Siklus : ............................................................................Hari
c. Banyaknya : ....................................................................................
d. Teratur / Tidak teratur : ....................................................................................
e. Lamanya : ....................................................................................
f. Sifat darah : ....................................................................................
g. Dismenorhoe : ....................................................................................

4. Riwayat Perkawinan :
a. Status Perkawinan : ........................................., Kawin : .....................................kali
b. Kawin 1 : Umur............... Tahun, dengan suami umur ............ Tahun
Lamanya : ................... Tahun, Anak : ....................... Orang
c. Kawin 2 : Umur............... Tahun, dengan suami umur ............. Tahun
Lamanya : ................... Tahun, Anak : ......................... Orang

5. Riwayat Kehamilan, Persalinan dan Nifas yang lalu :

TEMPA UMU ANAK
TGL/TAH JENIS KEADAAAN
N T R PENOLO PENYUL
UN PERSALIN NIFAS ANAK
O PARTU HAMI NG IT JNS BB PB
PARTUS AN SEKARANG
S L
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2
3
4
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6. Riwayat Laktasi : ..........................................................................................

7. Riwayat Hamil Ini : ...........................................................................................
a. HPHT : …........................................................................................
b. Taksiran persalinan : ............................................................................................

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 c. Trimester I : .................................................................................................
 Keluhan : …..............................................................................................
 ANC : .................................................... Imunisasi TT : ......................
 Penyuluhan yang pernah didapat : ........................................................................
 Theraphy : .................................................................................................
d. Trimester II : …..............................................................................................
 Keluhan : ..................................................................................................
 ANC : .................................................... Imunisasi TT : ......................
 Penyuluhan yang pernah didapat : .........................................................................
 Theraphy : ..................................................................................................
e. Trimester III : ..................................................................................................
 Keluhan : ................................................................................................
 ANC : .................................................... Imunisasi TT : ....................
 Penyuluhan yang pernah didapat : .........................................................................
 Theraphy : ..................................................................................................

f. Pergerakan Janin pertama kali dirasakan :...........................................................................

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Pergerakan janin dalam 24 jam terakhir : ............................................................................

8. Riwayat Keluarga Berencana :

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9. Riwayat Penyakit Sistemik :

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10. Riwayat Penyakit Yang lalu / Riwayat Operasi :

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 11. a. Penyakit Keluarga : ...........................................................................................
b. Riwayat Keturunan : ..........................................................................................
c. Kembar : ...........................................................................................

12. Kebiasaan Sehari – hari :

a. Personal Hygiene : .................................................................................................

b. Gizi : …...............................................................................................

c. Eliminasi : …................................................................................................

d. Istirahat : ...................................................................................................

e. Sexsualitas :…………………............................................................................

f. Pola Aktivitas : ...................................................................................................

g. Perokok : ...................................................................................................

h. Pemakai Obat2an : ....................................................................................................

13. Riwayat PsikoSosialSpiritual :

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PEMERIKSAAN FISIK ( Data Objektif )

1. Status Generalis :
a. Keadaan Umum : ...........................................................................
b. Keadaan Emosional : ...........................................................................
c. Kesadaran : ............................................................................
d. Tekanan Darah : .............................................................................
e. Tekanan Darah Sebelum Hamil : .............................................................................
f. Suhu : .............................................................................
g. Nadi : .............................................................................
h. Respirasi : .............................................................................
i. Tinggi Badan : .............................................................................
j. Berat Badan Sekarang : ..............................................................................
k. Berat badan sebelum Hamil : .............................................................................
l. Lingkar lengan Atas : ..............................................................................

2. Pemeriksaan Sistematis :
a. Kepala
1) Rambut : ..........................................................................................
2) Muka : ...........................................................................................
3) Mata
a) Conjungtiva : ...........................................................................................
b) Sklera : ............................................................................................
c) Palpabrae : .............................................................................................
4) Hidung : .............................................................................................
5) Telinga : ..............................................................................................
6) Mulut Gigi / Gusi : .............................................................................................

b. Leher
1) Kel. Gondok (Thyroid) : ................................................................................
2) Tumor : ................................................................................
3) Pembesaran Kelenjar Getah bening : ....................................................................
4) Vena Jugularis : .............................................................................................

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c. Dada dan Axilla (Ketiak)
1. Jantung : ......................................................................................................
2. Paru : ........................................................................................................
3. Mamae :
a) Membesar : ................................................................................................................
b) Tumor : .................................................................................................................
c) Simetris : .................................................................................................................
d) Areola : ................................................................................................................
e) Puting Susu : ...........................................................................................................................
f) Kolostrum : ...........................................................................................................................
g) Nyeri : ...........................................................................................................................

4. Axilla
a) Tumor : ...............................................................................................................
b) Nyeri : ..............................................................................................................

d. Perut : Status lokalis / Status obstetricus

e. Anogenital : Status lokalis
f. Ekstremitas :
1) Tungkai : ...........................................................................................
2) Varices : ............................................................................................
3) Edema : ............................................................................................
4) Refleks Patella : ............................................................................................
5) Keluhan lain : ............................................................................................

3. Pemeriksaan Khusus Obstetri (Status Lokalis ) :

a. Abdomen
1). Inspeksi
a) Membesar : ......................................... dengan arah memanjang / melebar
b) Pelebaran Vena : .....................Ada / Tidak
c) Linea : .....................Alba / Nigra
d) Striae : .....................Albican / Livide
e) Kelainan : ...........................................................................................
f) Pergerakan Anak : ............................................................................................
g) Luka Bekas Operasi : ............................................................................................

2) Palpasi
a) Kontraksi : .............................................................................................
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 b) Leopold I : TFU : .................................................(… …........... cm)
FU Terisi : .........................................................................
c) Leopold II : Kanan : ...............................................................................
Kiri : ................................................................................
d) Leopold III : Bagian Bawah terisi : ...............................................................
e) Leopold IV : .................................................................................................
f) Osborn Test : .................................................................................................
g) Taksiran Berat janin : .................................................................................................

3) Auskultasi :
DJJ : - Punctum maximum (PM) : ....................................................................
- Tempat : ....................................................................
- Frekuensi : ......................................................... teratur / tidak

b. Ano Genital
1) Kelainan : …………………................................................................................
2) Pengeluaran : .........................................................................................................
3) Inspekulo : - Vagina : .................................................................................
- Portio : .................................................................................
4) Pelvi Metri Klinis :
a) Promotorium : ..............................................................................
b) Conjugata Diagonalis : ...............................................................................
c) Conjugata Vera : ................................................................................
d) Linea Inominata : ...............................................................................
e) Dinding Samping / Side Wall : ................................................................................
f) Spina Ichiadica : ................................................................................
g) Distancia Interspinarum : ................................................................................
h) Sacrum : ................................................................................
i) Os Cocygeus : .................................................................................
j) Arcus Pubis : ................................................................................
k) Imbang Feto Pelvik : ................................................................................
l) Kesan Panggul : ................................................................................

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D. PEMERIKSAAN LABORATORIUM
Darah : HB :............................... % Gol. Darah : ..........................................................
Urine : Protein : ..................... Reduksi : ..........................................................
Pemeriksaan Penunjang Lain : .................................................................................................
USG : ........................................................................................................................................

STEP II : IDENTIFIKASI DIAGNOSA / MASALAH AKTUAL

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 DIAGNOSA/MASALAH
NO DATA DASAR ANALISA/INTERPRETASI
AKTUAL

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 DIAGNOSA/MASALAH
NO DATA DASAR ANALISA/INTERPRETASI
AKTUAL

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STEP III : IDENTIFIKASI DIAGNOSA/MASALAH POTENSIAL
DIAGNOSA/MASALAH
NO DATA DASAR ANALISA/INTERPRETASI
POTENSIAL

STEP IV : TINDAKAN EMERGENCY

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STEP V : RENCANA TINDAKAN ASUHAN KEBIDANAN
DX: MASALAH/ PERENCANAAN

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N AKTUAL/
TUJUAN RASIONAL
O POTENSIAL INTERVENSI

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STEP VI/VII : IMPLEMENTASI/EVALUASI ASUHAN KEBIDANAN

N
TUJUAN IMPLEMENTASI EVALUASI
O
1 2 3 4

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 , ...........................................................20..

Pemeriksa

( ................................................. )

CT / Pembimbing Institusi CI / Pembimbing Lahan

( ............................................. ) ( .............................................. )

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