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ASUHAN KEBIDANAN PADA NY.

B MASA HAMIL
SAMPAI DENGAN PELAYANAN NEONATUS
DI KLINIK.............................

LAPORAN TUGAS AKHIR

Oleh:

YAYASAN EKA HARAP PALANGKA RAYA


SEKOLAH TINGGI ILMU KESEHATAN
Jln. Beliang No. 110 Telp. (0536) 3227707
Email : ekaharap@yahoo.com
Lampiran 2 : LEMBAR PERSETUJUAN

LEMBAR PERSETUJUAN

Laporan Studi Kasus ini Telah di Setujui untuk di syahkan sebagai


Laporan Tugas Akhir dengan Judul Asuhan Kebidanan Pada Ny.
B Masa Hamil Sampai Dengan Pelayanan Keluarga Berencana
Di Klinik.............................

Pada Tanggal ……………………..


Mahasiswa

Silvia Wulandari
NIM. 2015.A.06.2090

Pembimbing Klinik Pembimbing Institusi

Xxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxx
NIP. ……………………. NIDN/NIK…………… …

Mengetahui,
Ketua Program Studi DIII Kebidanan
STIKes Eka Harap

Desi Kumala F., SST., M.Kes


NIDN. 26128702
Lampiran 3 : LEMBAR PENGESAHAN
LEMBAR PENGESAHAN

Laporan Studi Kasus ini Telah di Setujui untuk di syahkan sebagai


Laporan Tugas Akhir dengan Judul Asuhan Kebidanan Pada Ny. B
Masa Hamil Sampai Dengan Pelayanan Keluarga Berencana Di
Klinik.............................
Pada Tanggal ……………………..

Mahasiswa

Silvia Wulandari
NIM. 2015.A.06.2017

Pembimbing Klinik Pembimbing Institusi

Xxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxx
NIP. ……………………. NIDN/NIK………………

Mengetahui,
Ketua STIKes Eka Harap Ketua Program DIII Kebidanan

Maria Adelheid Ensia, S.Pd., M.Kes Desi Kumala F., SST., M.Kes
NIDN. ………………. NIDN. 26128702
KATA PENGANTAR
DAFTAR ISI
Hal
Sampul ................................................................................................................. i
Lembar Persetujuan ............................................................................................. ii
Lembar Pengesahan............................................................................................. iii
Kata Pengantar..................................................................................................... iv
Daftar Isi.............................................................................................................. v
Daftar Lampiran................................................................................................... vi

BAB I PENDAHULUAN
1.1 Latar Belakang................................................................................
1.2 Rumusan Masalah...........................................................................
1.3 Tujuan................................................................ ............................
1.4 Manfaat …………..........................................................................
BAB II TINJAUAN PUSTAKA
2.1 Konsep Teori Antenatal Care (ANC)............................................
2.1.1. Definisi Antenatal Care (ANC)..............................................
2.1.2. Tujuan Antenatal Care (ANC)...............................................
2.1.3. Standar Pelayanan Antenatal Care (ANC).............................
2.1.4. Jadwal kunjungan Asuhan Antenatal.....................................
2.1.5. Konsep Anemia………………..............................................
2.1.6. Klasifikasi Anemia……………….........................................
2.1.7. Etiologi Anemia.....................................................................
2.1.8. Patofisiologi Anemia pada Ibu Hamil....................................
2.2 Konsep Teori Intranatal Care (INC).....................................

2.1.2. Definisi Intranatal Care (INC)................................


Dll……..
2.3 Konsep Teori Postnatal Care (PNC).....................................
2.3.1 Definisi Postnatal Care (PNC)……………….
Dll…………..
2.4 Konsep Teori Bayi Baru Lahir (BBL)……..
2.4.1 Definisi Bayi baru lahir………
Dll………….
2.5 Konsep Manajemen Asuhan Kebidanan ANC, INC, PNC, dan Bayi Baru
Lahir Menggunakan Varney…..
2.5.1 Pengkajian ………………….
2.5.2 Interpretasi Data…………….
2.5.3 Diagnosa Masalah pontensial………..
2.5.4 Indentifikasi Kebutuhan Segera……….
2.5.5 Intervensi…………….
2.5.6 Implementasi……………….
2.5.7 Evaluasi…………………

BAB III TINJAUAN KASUS


3.1 Tinjauan kasus Asuhan pada Ibu Hamil
1. Pengkajian.......................................................................
2. Interpretasi Data..................................................................
3. Diagnosa masalah potensial.....................................................
4. Identifikasi kebutuhan segera…..............................................
5. Intervensi...............................................................................
6. Implementasi.....................................................................
7. Evaluasi …………………………………………….
3.2 Tinjauan kasus Asuhan pada Ibu Bersalin………………….
1. Pengkajian.......................................................................
2. Interpretasi Data..................................................................
3. Diagnosa masalah potensial.....................................................
4. Identifikasi kebutuhan segera…..............................................
5. Intervensi.......................... .....................................................
6. Implementasi.....................................................................
3.3 Tinjauan kasus Asuhan pada Ibu Nifas………………….

1. Pengkajian.......................................................................
2. Interpretasi Data..................................................................
3. Diagnosa masalah potensial.....................................................
4. Identifikasi kebutuhan segera…..............................................
5. Intervensi.......................... .....................................................
6. Implementasi.....................................................................
7. Evaluasi...............................................................................
3.4 Tinjauan kasus Asuhan pada Bayi Baru Lahir………………….
1. Pengkajian.......................................................................
2. Interpretasi Data..................................................................
3. Diagnosa masalah potensial.....................................................
4. Identifikasi kebutuhan segera…..............................................
5. Intervensi.......................... .....................................................
6. Implementasi.....................................................................
7. Evaluasi...............................................................................
BAB IV PEMBAHASAN
BAB V TINJAUAN KASUS
5.1 Kesimpulan
5.2 Saran
DAFTAR PUSTAKA
DAFTAR LAMPIRAN

Lampiran 1 Partograf
Lampiran 5 Informed Consent
Lampiran 6 Lemabar Konsultasi LTA
BAB I
PENDAHULUAN

1.1 Latar Belakang

1.2 Rumusan Masalah

1.3 Tujuan
1.3.1 Tujuan Umum

1.3.2 Tujuan Khusus

1.4 Manfaat
1.4.1 Bagi Institusi

1.4.2 Bagi Lahan Praktik


Identifikasi Ruang Lingkup Asuhan
Adapun ruang lingkup dari laporan studi kasus ini untuk
melakukan asuhan kebidanan yang komprehensif pada Ny...... dengan
kehamilan Trimester ke-3 yang fisiologi, bersalin, nifas, dan neonatus
di Klinik .................

Tujuan
Penyusun
LTA
TUJUAN
1.3.1. TUJUAN UMUM
Memberikan asuhan kebidanan secara continuity care kepada
Ny. B dari hamil trimester III, bersalin, nifas, bayi baru lahir
fisiologis di klinik .............dengan menggunakan pendekatan
manajemen Kebidanan.
1.3.2 Tujuan Khusus
1. Melakukan Asuhan Kebidanan pada Ibu Hamil Secara Continuity Care
2. Melakukan Asuhan Kebidanan pada Ibu Bersalin Secara Continuity Care
3. Melakukan Asuhan Kebidanan pada Ibu Masa Nifas Secara Continuity Care
4. Melakukan Asuhan Kebidanan pada Ibu Bayi Baru Lahir Secara
Continuity Care
5. Mendokumentasikan Asuhan Kebidanan yang telah dilakukan
pada Ibu Hamil, Bersalin, Nifas, Bayi Baru dalam bentuk Askeb
varney, catatan perkembangan menggunakan SOAP

Sasaran, Tempat, dan Waktu Asuhan kebidanan


1.Sasaran
Ny B hamil fisiologi trimester III yang berdomisili di Jalan
Tempat
Asuhan continuity care pada Ny.B akan dilakukan diklinik
............dengan alasan bahwa klinik ................
Waktu
Pelaksanaan asuhan kebidanan pada Ny.B akan dilakukan mulai dari
bulan Januari ..............sampai .............diklinik .................
BAB II
TINJAUHAN PUSTAKA

Konsep Dasar Kehamilan


Konsep Dasar Persalinan
Konsep dasar Masa Nifas
Konsep Dasar Bayi Baru Lahir
BAB III
PENDOKUMENTASIAN ASUHAN
KEBIDANAN
FORMAT PENGKAJIAN PADA IBU
HAMIL

3.1 PENGKAJIAN
Hari/Tanggal : ………………
Pukul : ………………
3.1.1 Data Subjektif
1. IDENTITAS/BIODATA
Nama Ibu : ..................................... Nama Suami : .......................................
Umur : ..................................... Umur : .......................................
Suku/Bangsa : ..................................... Suku/Bangsa : .......................................
Agama : ..................................... Agama : .......................................
Pendidikan : ..................................... Pendidikan : .......................................
Pekerjaan : ..................................... Pekerjaan : .......................................
Alamat Rumah : ..................................... Alamat Rumah : .......................................
Telepon : ..................................... Telepon : .......................................
2. Kunjungan yang ke- ...................
3. Alasan kunjungan/keluhan utama :
....................................................................................................................................................
.....
..............................................................................................................................................
...........
4. Riwayat Menstruasi
a. Menarche : ...................... tahun
b. Siklus menstruasi : ...................... hari (teratur / tidak teratur)
c. Lama : ...................... hari
d. Banyak darah : ......................
e. Konsistensi : ......................
f. Dysmenorhea : ya / tidak (sebelum / selama / sesudah menstruasi)
g. Fluor albus : ya / tidak (sebelum / selama / sesudah menstruasi)
h. HPHT : ...................................
i. TPL : ...................................
5. Status Perkawinan
a. Kawin : ya / tidak jika kawin berapa kali : ....................
b. Lama perkawinan : ...................... tahun
6. Riwayat kehamilan, Persalinan dan Nifas yang lalu
No Suami ke Kehamilan Persalinan Nifas Anak KB Ket.
Umur Penyullit Penol Jenis Tempt PenyulitPenyulit JK BB PB H/M

7. Riwayat Kehamilan Sekarang


a. Hamil yang ke .................... dengan usia kehamilan ........................... minggu.

b. Gerak anak dirasakan pertama kali pada usia kehamilan ................. minggu
c. Selama hamil memeriksakan kehamilan di ........... berapa kali .....................
d. Keluhan yang di rasakan selama hamil ini:
Trimester I
: .....................................................................................................................................
....
Trimester II
: .....................................................................................................................................
....
Trimester III
: .....................................................................................................................................
....
8. Riwayat kesehatan :
Penyakit yang pernah atau sedang diderita :
Penyakit Klien Keluarga
Jantung
Hipertensi
Hepar / hepatitis
Diabetes Mellitus
Anemia
ringan/sedang/berat
PHS dan HIV/AIDS
Campak
Malaria
Tuberkulosis (TBC)

Ketunan kembar
: .............................................................................................................................
Dari pihak siapa
: .............................................................................................................................
9. Riwayat Psikososial
1). Kehamilan ini [ ] Direncanakan[ ] Tidak direncanakan [ ] Diterima [ ] Tidak
diterima
2). Perasaan tentang kehamilan ini
: .............................................................................
3). Emosional ibu saat pengkajian : [ ]stabil [ ]labil
4). Jenis kelamin yang diharapkan : [ ]♀ [ ]♂
5). Susunan keluarga / Genogram :
6). Perilaku kesehatan :Merokok [ ] ya [ ] tidak
Alkohol [ ] ya [ ] tidak
Narkoba [ ] ya [ ] tidak
Obat / jamu [ ] ya [ ] tidak
7). Ibadah / Spiritual : Patuh / tidak patuh
8). Tempat dan petugas yang diinginkan untuk
bersalin: .....................................................................
10. Riwayat KB
[ ] pernah [ ] belum pernah
Mulai KB : ……………….. Jenis KB : ……………………..
Lama Memakai : ……………….. Kapan berhenti : ……………………..
Alasan Berhenti : ...............................................................................................................

11. Pola kebiasaan sehari-hari


a. Pola Nutrisi
Makan
Minum
b. Pola Eliminasi
BAK
BAB
c. Pola Istirahat dan Tidur
d. Pola Aktifitas
e. Personal Hygiene
Mandi : ............ x/hari keramas : ............ x/hari
Gosok gigi : ............ x/hari Ganti pakaian Dalam : ............ x/hari
f. Seksualitas
.........................................................................................................................................
12. Riwayat Imunisasi
Imunisasi : TT : [ ] pernah [ ] belum pernah
Tanggal : TT1 : .............. TT2 : ................. TT3 : .................TT4 : ................TT5 :
3.1.2 DATA OBJEKTIF
1. Pemeriksaan umum
a. Kesadaran : .........................
b. Tekanan darah : ............ mmHg
c. Suhu : ............ ºC
d. Nadi : ............ x/menit
e. RR : ............ x/menit

f. BB (pertama periksa) : ............ Kg


g. BB (sekarang saat periksa) : ............ Kg
h. TB : ............ cm
i. Lingkar lengan atas : ............ cm
2. Pemeriksaan Khusus
a. Kepala :
b. Muka :
c. Mata :
d. Mulut dan Gigi:
e. Hidung :
f. Telinga :
g. Leher :
h. Axila :
i. Dada :
j. Abdomen :
Leopold I : .........................................................................................................
Leopold II : .........................................................................................................
Leopold III : .............................................................................................
Leopold IV : ............................................................................................
TBBJ : ................................. gr
Pembesaran Liver :
Pembesaran Limpa :
k. Genetalia :
l. Anus :
m. Ekstremitas :
n. Punggung :
3. Pemeriksaan Penunjang
Tanggal : ..............................
a. Ukuran panggul luar
Distansia spinarum : .................... cm Distansia kristarum: .............. cm
Conjugata eksterna : .................... cm Lingkar panggul : .............. cm
b. Pemeriksaan laboratorium
Darah : Golongan darah : ...................................
HB : ...................................
Urine : Protein Urine : ...................................
Reduksi urine : ...................................

3.2 INTERPRETASI DATA


1. Data Subjektif :
a. .....................................................................................................................................
b. .....................................................................................................................................
2. Data Objektif :
a. .................................................................................................................................
....
b. .................................................................................................................................
....
3. Diagnosa: ........................................................................................................................
.................
3.3 DIAGNOSA / MASALAH POTENSIAL
Diagnosa / Masalah Potensial ...............................................................................
3.4 IDENTIFIKASI KEBUTUHAN SEGERA
1. ......................................................................................................................
2. ......................................................................................................................
3.5 INTERVENSI
1. ......................................................................................................................
2. ......................................................................................................................
3. ......................................................................................................................
4. ......................................................................................................................
3.6 IMPLEMENTASI
Hari / Tanggal / Jam : .......................................................................................
1. ......................................................................................................................
2. ......................................................................................................................
3. ......................................................................................................................
4. ......................................................................................................................
3.7 EVALUASI
Hari / Tanggal / Jam : .......................................................................................
1. ......................................................................................................................
2. ......................................................................................................................
Palangka Raya,
Mahasiswa
................................
Mengetahui,

Pembimbing Klinik Pembimbing Institusi

Xxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxx
NIP. ……………………. NIDN/NIK………………
3.2 CATATAN PERKEMBANGAN KEHAMILAN
Tanggal : Pukul : .............WIB

SUBJEKTIF
OBJEKTIF
ANALISA
PENATALAKSANAAN

Palangka Raya,
Mahasiswa
................................

Pembimbing Klinik Pembimbing Institusi

Xxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxx
NIP. ……………………. NIDN/NIK………………
YAYASAN EKA HARAP PALANGKARAYA
SEKOLAH TINGGI ILMU KESEHATAN
PROGRAM STUDI DIII KEBIDANAN
Jln. Beliang No. 110 Telp. (0536) 3227707

Nama Mahasiswa :
NIM :
Tempat Praktek :
Tanggal Pengkajian :

FORMAT PENGKAJIAN PADA IBU BERSALIN


I PENGKAJIAN DATA
1. IDENTITAS/BIODATA
Nama Ibu : ............................................. Nama Suami : ........................................
Umur : ............................................. Umur : ........................................
Suku/Bangsa : ............................................. Suku/Bangsa : ........................................
Agama : ............................................. Agama : ........................................
Pendidikan : ............................................. Pendidikan : ........................................
Pekerjaan : ............................................. Pekerjaan : ........................................
Alamat ........................................
Alamat Rumah : ............................................. :
Rumah
Telepon : ............................................. Telepon : ........................................

2. ANAMNESA (Data Subjektif)


Pada tanggal : ................................ Pukul : ......................
1. Alasan kunjungan/keluhan utama :
..............................................................................................................................................
2. Riwayat Menstruasi
1. Menarche : .....................................
.... tahun
2. Siklus menstruasi
: ......................................... hari
(teratur/tidak teratur)
3. Lama : ......................................... hari
4. Banyak darah
: .........................................
5. Konsistensi : .....................................
....
6. Disminorhea : .....................................
.... (sebelum / selama / sesudah menstruasi)
7. Flour Albus
: ......................................... (sebelum
/sesudah menstruasi) Warna ..................... Bau ....................... Gatal.......................
8. HPHT : .....................................
....
9. TP : .........................................
2. Tanda-tanda bersalin :
a. Kontraksi : .......................... Sejak Tanggal
: ........................
b. Frekuensi : .......................... X / 10 menit Lamanya
: ........................ detik
c. Kekuatan : .......................... Lokasi : .........................
d. Darah dan lendir : [ ]ada [ ]tidak ada
e. Air Ketuban : [ ]ada [ ]tidak ada Jumlah : ........... Warna: .................
f. Darah : [ ]ada [ ]tidak ada Jumlah : ........... Warna: .................
3. Status Perkawinan
1. Kawin : Ya / Tidak
2. Lama perkawinan : ..................
tahun
4. Riwayat Kehamilan, Persalinan, dan Nifas yang Lalu:
No Sua Kehamilan Persalinan Anak KB Ket.
mi Umur Penyu Penolon Jenis Temp Penyul JK B T A H/M
Ke lit g P. . it B B SI

5. Riwayat Kehamilan Sekarang


Hamil yang ke .................... dengan usia kehamilan ........................... minggu.
3. Gerak anak dirasakan pertama kali pada usia kehamilan ................. minggu
Bila pergerakan sudah terasa, pergerakan anak dalam 24 jam :
1. [ ] kurang dari 10 kali
2. [ ] lebih dari 10 sampai 20 kali
3. [ ] lebih dari 20 kali
Bila lebih dari 20 kali dalalam 24 jam, dengan frekuensi :
 [ ] kurang dari 15 detik
 [ ] lebih dari 15 detik
 [ ] .............................
Bila ada pergerakan keluhan yang dirasakan :
.................................................................................................................................
4. Selama hamil memeriksakan kehamilan di ........... berapa kali .....................
5. Keluhan yang di rasakan selama hamil ini:
Trimester I
: .....................................................................................................................................
....
Trimester II
: .....................................................................................................................................
....
Trimester III
: .....................................................................................................................................
....
1. Riwayat kesehatan:
Penyakit yang pernah atau sedang diderita :
Penyakit Klien Keluarga
Jantung
Hipertensi
Hepar / hepatitis
Diabetes Mellitus
Anemia
ringan/sedang/berat
PHS dan HIV/AIDS
Campak
Malaria
Tuberkulosis (TBC)

Ketunan kembar
: .............................................................................................................................
Dari pihak siapa
: .............................................................................................................................

2. Riwayat Psikososial
a. Kehamilan ini [ ] Direncanakan[ ] Tidak
direncanakan [ ] Diterima [ ] Tidak diterima
b. Perasaan tentang kehamilan ini
: .............................................................................
c. Emosional ibu saat pengkajian : [ ]stabil [
]labil
d. Jenis kelamin yang diharapkan : [ ]♀ [
]♂
e. Perilaku kesehatan :Merokok [ ] ya [
] tidak
Alkohol [ ] ya [ ] tidak
Narkoba [ ] ya [ ] tidak
Obat / jamu [ ] ya [ ] tidak
f. Ibadah / Spiritual : Patuh / tidak patuh
g. Tempat dan petugas yang diinginkan untuk
bersalin: .....................................................................
3. Riwayat KB [ ] pernah [ ] belum pernah
Mulai KB : ……………….. Jenis KB : ……………………..
Lama : ……………….. Kapan berhenti : ……………………..
Alasan : ...............................................................................................................
4. Pola kebiasaan sehari-hari
a. Pola Nutrisi
Makan
Selama hamil ..............................................................................................................
Saat bersalin : ............................................................................................................
Minum
Selama hamil : ............ gelas /hari
Saat bersalin : ............ gelas /hari
5. Pola Eliminasi
BAK
Selama hamil : ............ x/hari Warna : Bau :
Saat bersalin : ............ x/hari Warna : Bau :
BAB
Seama hamill : ............ x/hari Warna : Konsistensi :
Saat bersalin : ............ x/hari Warna : Konsistensi :
6. Pola Istirahat dan Tidur
Selama hamil : Tidur siang : ........... jam/hari Tidur malam : ...........
jam/hari
Saat bersalin : Tidur siang : ........... jam/hari Tidur malam : ...........
jam/hari
7. Pola Aktifitas
Selama hamil : .....................................................................................................
Saat bersalin : ......................................................................................................
1. Personal Hygiene
Mandi : ............ x/hari keramas : ............ x/hari
Gosok gigi : ............ x/hari Ganti pakaian Dalam : ............ x/hari
2. Seksualitas : ......................................................................................................
3. Riwayat Imunisasi
Imunisasi : TT : [ ] pernah [ ] belum pernah
Tanggal : TT1 : .............. TT2 : .................TT3 : .................TT4 : ................TT5 : ................
6. PEMERIKSAAN FISIK (Data Objektif)
1. Pemeriksaan umum
a. Kesadaran : .........................
b. Tekanan darah : ............ mmHg Suhu : ............ ºC
c. Nadi : ............ x/menit RR : ............ x/menit
d. BB (pertama periksa) : ............ Kg
e. BB (sekarang saat periksa) : ............ Kg
f. TB : ............ cm
g. Lingkar lengan atas : ............ cm
2. Pemeriksaan Khusus
a. Inspeksi
 Kepala : warna rambut :...........................................................
Distribusi: ...............................................................................................
Kebersihan: ...................................................................................
Kekuatan : ...............................................................................................
Kulit kepala : .....................................................................
 Muka : wajah : pucat / oedem
Chloasma gravidarum : ada / tidak ada
 Mata : Conjungtiva : pucat / merah muda
Sklera : putih / kuning
Pupil : isokor / anisiokor / miosis / midriasis
Reaksi cahaya : positif / negatif
 Mulut dan Gigi : Gigi : karies / trismus / perdarahan gusi
Mukosa bibir : stomatitis
Lidah : bersih / kotor
 Hidung : Kesimetrisan : [ ]simetris [ ]tidak simetris
Secret : [ ]ada [ ]tidak ada
Kemampuan penciuman : [ ]baik [ ]tidak baik
 Telinga : Kesimetrisan : [ ]simetris [ ]tidak simetris
Serumen : [ ]ada [ ]tidak ada
Kemampuan pendengaran : [ ]baik [ ]tidak baik
 Leher : Pembesaaran kelenjar tiroid : [ ]ada [ ]tidak ada
Pembesaran vena jagularis : [ ]ada [ ]tidak ada
Pembesaran KGB : [ ]ada [ ]tidak ada
 Axila : Pembesaran KGB : [ ]ada [ ]tidak ada
 Dada : Kesimetrisan payudara : [ ]simetris [ ]tidak simetris
Pergerakan dada : [ ]reguler [ ]irreguler
Benjolan abnormal : [ ]ada [ ]tidak ada
Hiperpigmentasi areola : [ ]ada` [ ]tidak ada
Keadaan puting susu :[]menonjol [ ]datar [ ] tenggelam kedalam
 Abdomen : Pembesaran : ..................................................
Warna / hiperpigmentasi : .................................................................
Bekas luka / operasi : [ ]ada [ ]tidak ada
Linea (nigra/alba) : [ ]alba [ ]nigra [ ]tidak ada
Striae (livida / ablican) : [ ]livida [ ]albican [ ]tidak ada
 Genetalia : Warna vulva vagina : .................................................................
Luka parut : [ ]ada [ ]tidak ada
Varises : [ ]ada [ ]tidak ada
Tanda Chadwick : [ ]ada [ ]tidak ada
Oedem : [ ]ada [ ]tidak ada
Pengeluaran : [ ]bloody show [ ]cairan ketuban
[ ]darah segar [ ]nanah/pus
 Perinium : Bekas luka parut : [ ]ada [ ] tidak ada
Menonjol : [ ]iya [ ]tidak
Varises : [ ]ada [ ] tidak ada
 Anus : Hemorroid : [ ]ada [ ]tidak ada
 Ekstremitas : Atas : [ ]oedem [ ]varises [ ]kekakuan
Bawah : [ ]oedem [ ]varises [ ]kekakuan
b. Palpasi
 Leher : Pembesaran vena jugularis : [ ]ada [ ]tidak ada
Pembesaran kelenjar tyroid : [ ]ada [ ]tidak ada
Pembesaran KGB : [ ]ada [ ]tidak ada
 Dada : Benjolan / tumor : [ ]ada [ ]tidak ada
Keluaran kolostrum : .............................................
 Abdoment : TFU : .................................................................................................
Leopold I :
...............................................................................................................
Leopold II :
...............................................................................................................
Leopold III :
...............................................................................................................
Leopold IV :
...............................................................................................................
: Kontraksi : Intensitas : .................................
Lama : ................................. detik
Frekuensi : ................................. X / 10 menit
: TBBJ : ................................. gr
 Kandung Kemih: ..............................................................................................
 Ektremitas atas dan bawah : [ ]oedem [ ]varises
c. Auskultasi
 Dada : Auskultasi paru: [ ]vesikuler [ ]whezzing [ ]ronkhi
 Abdomen : DJJ : [ ]positif [ ]negatif .................. X/10 menit
: [ ]teratur [ ]tidak teratur
Bising usus : [ ]positif [ ]negatif
d. Perkusi : Reflek patella : [ ] positif [ ] negatif
: Ketuk costavertebra : [ ] nyeri [ ] tidak nyeri
: Pemeriksaan Ginjal : [ ]sakit [ ]tidak sakit
4. PEMERIKSAAN PENUNJANG
Tanggal: ..............................
1. Pemeriksaan Dalam (PD)
Serviks : Pendataran : ............................................................................................
Pembukaan : ............................................................................................................
Selaput ketuban: ........................................................................................................
Bagian terendah: ........................................................................................................
Penurunan : ............................................................................................................
Posisi : ............................................................................................................
Tali Pusat : ............................................................................................................
Kesan Panggul : ................................................................................................
2. Pemeriksaan laboratorium
Darah : Golongan darah : ...................................
HB : ...................................
Rhesus : ...................................

Urine : Protein Urine : ...................................


Reduksi urine : ...................................
Foto : Rotgen: ...................................
USG : ...................................
Pemeriksaan Penunjang lainnya :
.............................................................................................................................................
II. INTERPRESTASI DATA DASAR
Tanggal: ................................ Pukul: ..................................
Diagnosa:.............................................................................................................................
1. Data Subjektif :
a. .....................................................................................................................................
b. .....................................................................................................................................
2. Data Objektif :
a. ......................................................................................................................................
b. ......................................................................................................................................
c. ......................................................................................................................................
d. ......................................................................................................................................
III.Masalah Potensial
Tanggal: ................................ Pukul: ..................................
Diagnosa: ..........................................................................................................................
..................
1. Data Subjektif :
a. .....................................................................................................................................
b. .....................................................................................................................................
c. .....................................................................................................................................
2. Data Objektif :
a. .....................................................................................................................................
b. .....................................................................................................................................
c. .....................................................................................................................................
d. .....................................................................................................................................
e. .....................................................................................................................................
IV. Tindakan / kebutuhan segera
Tanggal: ................................ Pukul: ..................................
Diagnosa: .........................................................................................................................
............
Tindakan / kebutuhan segera:
1. .........................................................................................................................................
2. .........................................................................................................................................
V. INTERVENSI
Tanggal: ................................ Pukul: ..................................
Diagnosa: .............................................................................................................................
.................
a. .........................................................................................................................................
b. .........................................................................................................................................
c. .........................................................................................................................................
d. .........................................................................................................................................
e. .........................................................................................................................................
VI. IMPLEMENTASI
Tanggal: ................................ Pukul: ..................................
a. .........................................................................................................................................
b. .........................................................................................................................................
c. .........................................................................................................................................
d. .........................................................................................................................................
e. .........................................................................................................................................
VII. EVALUASI
Tanggal: ................................ Pukul: ..................................
Diagnosa: ............................................................................................................................
...........
a. .........................................................................................................................................
b. .........................................................................................................................................
c. .........................................................................................................................................
d. .........................................................................................................................................
e. .........................................................................................................................................

Palangka Raya, ..................................

Mahasiswa

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

Pembimbing Praktik Pembimbing Institusi

(.........................................) (.........................................)
3.2 CATATAN PERKEMBANGAN PERSALINAN
Tanggal : Pukul : .............WIB

SUBJEKTIF
OBJEKTIF
ANALISA
PENATALAKSANAAN

Palangka Raya,
Mahasiswa

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

Pembimbing Klinik Pembimbing Institusi

Xxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxx
NIP. ……………………. NIDN/NIK………………
YAYASAN EKA HARAP PALANGKARAYA
SEKOLAH TINGGI ILMU KESEHATAN
Jln. Beliang No. 110 Telp. (0536) 3227707

Nama Mahasiswa :
NIM :
Tempat Praktek :
Tanggal Pengkajian :

ASUHAN KEBIDANAN PADA IBU NIFAS


I. PENGKAJIAN DATA
IDENTITAS/BIODATA
Nama Ibu : ........................................... Nama Suami : .........................................
Umur : ........................................... Umur : .........................................
Suku/Bangsa : ........................................... Suku/Bangsa : .........................................
.........................................
Agama : ........................................... Agama :
..
Pendidikan : ........................................... Pendidikan : .........................................
Pekerjaan : ........................................... Pekerjaan : .........................................
Alamat Rumah : ........................................... Alamat Rumah : .........................................
Telepon : ........................................... Telepon : .........................................

ANAMNESA (Data Subjektif)


1. Riwayat Obstetri : G: ..... P: ..... A: .....
a. HPHT : ............................................... TP : .............................
b. Keluhan-keluhan
: .....................................................................................................................................
....
.........................................................................................................................................
c. Riwayat ANC :
TM I : …… kali
Komplikasi : …………………………………………………………
Penanganan : …………………………………………………………
TM II : …… kali
komplikasi : ………………………………………………………....
Penanganan : …………………………………………………………
TM III : …… kali
komplikasi : ………………………………………………………….
Penanganan : ………………………………………………………….
2. Riwayat Persalinan
a. Tempat melahirkan : .....................................
b. Ditolong oleh : ..................................
c. Tanggal : .....................................
d. Pukul : ..................................
e. Jenis Persalinan : .....................................
f. Lama persalinan :
- Kala I : .................................... jam ........................................... menit
- Kala II : .................................... jam ........................................... menit
- Lamanya : .................................... jam ........................................... menit
Ketuban pecah : [ ]spontan [ ]dipecahkan pukul : ........................
Warna : ...................... bau / tidak jumlah : ...................... cc

e. Riwayat kesehatan
………………………………………………………………………………………
………………………………………………………………………………………
f. Riwayat Kesehatan
………………………………………………………………………………………
g. Riwayat Psikososial
Status Emosional : [ ]stabil [ ]labil
Interaksi Ibu dan Anak: ………………………………………………………………
h. Riwayat kebiasaan
Pola Makan
Saat bersali
Makan sehari-
hari : ................................................................................................................................
.........
Saat Nifas
Makan sehari-hari :
.........................................................................................................................................
Saat bersalin
Minum sehari-hari :
…………………………………………………………………………………………
Saat Nifas
Minum sehari-hari :
.........................................................................................................................................

a. Pola eliminasi :
BAB : ...... x sehari konsistensi : ................... warna : .......................
Keluhan saat
BAB: ...............................................................................................................................
BAK : ...... x sehari warna : ..........................
Keluhan saat
BAK : ..............................................................................................................................
.
b. Personal Hygiene
Mandi : ............ x/hari keramas : ............ x/hari
Gosok gigi : ............ x/hari Ganti pakaian Dalam : ............ x/hari

c. Aktivitas sehari-hari
.........................................................................................................................................
d. Pola istirahat dan tidur
Tidur siang : ............ jam/hari Tidur malam : ............ jam/hari
e. Seksualitas :
.........................................................................................................................................
i. Riwayat Imunisasi
TT [ ] dapat [ ] tidak dapat berapa kali : ............ kali
tanggal : I ................. II ............... III ............... IV ............... V ...............

2. PEMERIKSAAN FISIK (Data Objektif)


Keadaan Umum : [ ]baik [ ]buruk
Tanda Vital :
TD : ………….. mmHg N : ……… x/menit RR : ………. x/menit S : ………. ˚C
a. Kepala dan rambut
Warna rambut :....................................................................................................
Distribusi :..............................................................................................................
...............
Kebersihan :..............................................................................................................
...............
Kekuatan :..............................................................................................................
...............
Keadaan
kulit kapala :.................................................................................................................
b. Muka
Oedema : [ ]ada [ ]tidak ada
Chloasmagravidarum : [ ]ada [ ]tidak ada
c. Mata
Conjungtiva : .............................................................................................................
.................................
Skelera : .............................................................................................................
.................................
d. Mulut
Gigi : .............................................................................................................
.................................
Gusi : .................................................................................................
.............................................
Mukosa bibir
: .....................................................................................................................................
........
e. Telinga
Kesimetrisan : .................................................................................................
............................................
Serumen : [ ]ada [ ]tidak ada
Kemampuan
pendengaran: ......................................................................................................
f. Hidung
Cairan hidung : [ ]ada [ ]tidak ada
Kemampuan penciuman :.................................................................................................
b. Leher
Pembesaaran kelenjar tiroid: [ ]ada [ ]tidak ada
Pembesaran vena jagularis : [ ]ada [ ]tidak ada
Pembesaran KGB : [ ]ada [ ]tidak ada
c. Dada
Simetris : [ ]simetris [ ]tidak simetris
Pergerakan dada : [ ]reguler [ ]tidak teratur

i. Mammae
Kesimetrisan : [ ]simetris [ ]tidak simetris
Benjolan : [ ]ada [ ]tidak ada
Hiperpigmentasi areola : [ ]ada` [ ]tidak ada
Bentuk payudara : ..........................................................................................
Keadaan puting susu : [ ]menonjol keluar [ ]tenggelam kedalam
Cairan yang keluar :
..............................................................................................................
j. Abdomen
TFU : ...............................................................................
Kontraksi : [ ]baik, keras [ ]jelek, lembek
Supra Pubik : [ ]nyeri tekan [ ]tidak nyeri
BAK 2 jam Post Partum : [ ]sudah (pukul) ........... [ ]belum
k. Genitalia
Vulva/Vagina :episiotomi : [ ]ya [ ]tidak
jika iya :
 Anestesi lokal : [ ]ya [ ]tidak
 Jenis episiotomi : [ ]lateral kanan [ ]lateral kiri [ ]medial [ ]mediolateral
Laserasi :[ ]Tk I [ ]Tk II [ ]Tk III [ ]Tk IV
Oedema : [ ]ada [ ]tidak ada
Pengeluaran Pervaginam
 Lochia : [ ]ya [ ]tidak
 Jumlah : .........................................................................................
 Warna : [ ]merah [ ]merah-kuning [ ]kuning [ ]putih
 Bau : .....................................................................................
.........
 Jenis Lochia : [ ]rubra [ ]sanguinolenta [ ] serosa
[ ]alba [ ]purunlenta
l. Ekstemitas
Tangan : Kuku : [ ]bersih [ ]kotor
Oedema : [ ]ada [ ]tidak ada
Kaki :Varises : [ ]ada [ ]tidak ada
Oedema : [ ]ada [ ]tidak ada
Nyeri tekan : [ ]ya [ ]tidak
3. PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium
Tanggal : ..................................
Darah : HB : .......................... Golongan darah : ......................
Urine : Protein Urine: .......................... Glukosa Urine : ...................................
2. Pemeriksaan Penunjang Lainnya
..............................................................................................................................................

II. INTERPRESTASI DATA DASAR


Tanggal: ................................ Pukul: ..................................
Diagnosa: ........................................................................................................................
...............
1. Data Subjektif :
a. .................................................................................................................................
....
b. .................................................................................................................................
....
c. .................................................................................................................................
....
d. .................................................................................................................................
....
e. .................................................................................................................................
....
2. Data Objektif :
a. ..................................................................................................................................
....
b...................................................................................................................................
....
c. ..................................................................................................................................
....
d...................................................................................................................................
....
e. ..................................................................................................................................
....
III. Masalah Potensial
Tanggal: ................................ Pukul: ..................................
Diagnosa: .......................................................................................................................
.....................
1. Data Subjektif :
a. .................................................................................................................................
....
b. .................................................................................................................................
....
c. .................................................................................................................................
....
2. Data Objektif :
a. .................................................................................................................................
....
b. .................................................................................................................................
....
c. .................................................................................................................................
....
d. .................................................................................................................................
....
e. .................................................................................................................................
....
IV. Tindakan / kebutuhan segera
Tanggal: ................................ Pukul: ..................................
Diagnosa: .....................................................................................................................
...................
Tindakan / kebutuhan segera:
1. ......................................................................................................................................
...
2. ......................................................................................................................................
...

V. INTERVENSI
Tanggal: ................................ Pukul: ..................................
Diagnosa: ........................................................................................................................
..............
a. ......................................................................................................................................
...
b. ......................................................................................................................................
...
c. ......................................................................................................................................
...
d. ......................................................................................................................................
...
e. ......................................................................................................................................
...
VI. IMPLEMENTASI
Tanggal: ................................ Pukul: ..................................
a. ......................................................................................................................................
...
b. ......................................................................................................................................
...
c. ......................................................................................................................................
...
d. ......................................................................................................................................
...
e. ......................................................................................................................................
...

VII. EVALUASI
Tanggal: ................................ Pukul: ..................................
Diagnosa: .............................................................................................................................
a. ......................................................................................................................................
...
b. ......................................................................................................................................
...
Palangka
Raya, ..................................

Mahasiswa

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

Pembimbing Praktik / Lahan Pembimbing Institusi

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

YAYASAN EKA HARAP PALANGKARAYA


SEKOLAH TINGGI ILMU KESEHATAN
Jln. Beliang No. 110 Telp. (0536) 3227707
Nama Mahasiswa :
NIM :
Tempat Praktek :
Tanggal Pengkajian :

FORMAT PENGKAJIAN PADA BAYI BARU LAHIR (BBL) ATAU NEONATUS


(KN 6 JAM)

I. PENGKAJIAN DATA
A. IDENTITAS/BIODATA
a. Bayi
Nama Bayi : .............................................
Umur Bayi : .............................................
Tanggal/Jam Lahir: .............................................
Jenis Kelamin : .............................................
b. Orang Tua
Nama Ibu : ..................................... Nama Ayah : ......................................
Umur : ..................................... Umur : .....................................
Suku/Bangsa : ..................................... Suku/Bangsa : ......................................
Agama : ..................................... Agama : ......................................
Pendidikan : ..................................... Pendidikan : ......................................
Pekerjaan : ..................................... Pekerjaan : ......................................
Alamat Alamat ......................................
: ..................................... :
Rumah Kantor
Telepon : ..................................... Telepon : ......................................

B. ANAMNESA (Data Subjektif)


Tanggal : ............................. Pukul : ...............
oleh : ......................
1. Riwayat kehamilan : G : ..... P : ..... A : .....
ANC : TM I : …… kali TM II : …… kali TM III : …… kali
Komplikasi kehamilan:
.....................................................................................................
Kenaikan BB ibu : .................... Imunisasi TT : ........................
2. Riwayat kelainan dalam kehamilan :
[ ]Perdarahan [ ]Preeklamsia [ ]Eklampsia [ ]
anemia
[ ]Penyakit Kelamin [ ]Lainnya(sebutkan)……………….
3. Kebiasaan waktu hamil :
a. Makanan : .................................................................................................
...................................
b. Obat-obatan/jamu :
.....................................................................................................................................
c. Alkohol : [ ]ya [ ]tidak Merokok : [ ]ya [ ]tidak
d. Lain-lain :
.....................................................................................................................................
4. Riwayat persalinan sekarang :
d. Jenis persalinan : ……………………. Ditolong oleh : …………………….
e. Lama persalinan :
- Kala I : .................................... jam ...........................................
menit
- Kala II : .................................... jam ...........................................
menit
- Lamanya : .................................... jam ...........................................
menit
f. Ketuban pecah : spontan / dipecahkanpukul : .................. WIB
Warna : ...................... bau / tidak jumlah : ............. cc
g. Komplikasi persalinan
Ibu : .........................................................................................................................
............
Bayi : .........................................................................................................................
............
h. Keadaan BBL
Segera menanggis saat lahir :
.....................................................................................................................................
Tonus otot
: .........................................................................................................................
............
i. Resusitasi
- Pengisapan lendir : [ ]ya [ ]tidak rangsangan : [ ]ya [ ]tidak
- Massage jantung : [ ]ya [ ]tidak lamanya : [ ]ya [ ]tidak
- Oksigen : [ ]ya [ ]tidak lamanya :............. ltr/menit
- Terapi : .....................................................................................
.....
- Keterangan : .....................................................................................
.....

C. PEMERIKSAAN FISIK BAYI


a. Pemeriksaan fisik
Keadaan umum
1. Penampilan keseluruhan : [ ]normal [ ]tidak normal
2. Kepala, badan dan ekstrimitas: [ ]normal/lengkap [ ]tidak normal
3. Tonus otot, tingkat aktivitas : [ ]baik [ ]jelek
4. Warna kulit dan bibir: ...............................................................................................
5. Tangis bayi : ...............................................................................................
Tanda-tanda vital
1. Laju nafas (40-60x/menit) :
.....................................................................................................................................
2. Laju jantung (120-160x/menit) :
.....................................................................................................................................
3. Suhu (36,5-37,2ºC di ketiak)
: .........................................................................................................................
............
4. Berat badan :
.....................................................................................................................................
5. Panjang badan (45-53 cm) :
.....................................................................................................................................
Kepala
1. Ubun-ubun :
...............................................................................................................................
2. Sutura, molase :
………………………………………………………………………………
3. Ukuran lingkar kepala :
Fronto Oksipitalis : ..................... cm Sub Oksipito Bregmantika: ..................... cm
Mento Oksipitalis : ..................... cm Sub Mento Bregmatika: ..................... cm
Telinga
1. Kesimetrisan dengan mata : [ ]simetris [ ]asimetris
Mata
1. Tanda-tanda infeksi/Pus :
..............................................................................................................................
Hidung dan mulut
1. Bibir dan palatum : [ ]normal [ ]tidak normal
2. Periksa adanya sumbing : [ ]ada [ ]tidak ada
3. Refleks isap, saat menyusu :
...............................................................................................................................
Leher
1. Pembengkakan : .....................................................................................
........................................
2. Kelainan :
………………………………………………………………………………
Dada
1. Bentuk : .....................................................................................
..........................................
2. Puting : [ ]menonjol keluar [ ]tenggelam kedalam
3. Bunyi nafas :
...............................................................................................................................
4. Bunyi jantung
: .........................................................................................................................
......
Bahu, lengan, dan tangan
1. Gerakan normal :
………………………………………………………………………………..
2. Jumlah jari :
………………………………………………………………………………..
Perut
1. Bentuk : .....................................................................................
........................................
2. Penonjolan tali pusat saat menangis : [ ]ada [ ]tidak ada
3. Perdarahan tali pusat (3 pembuluh) : [ ]ada [ ]tidak ada
4. Lembek (pada saat tidak Menangis) : [ ]ya [ ]tidak
5. Tonjolan/ massa : [ ]ada [ ]tidak ada
Kelamin laki-laki
1. Testis berada di skrotum : [ ]ya [ ]tidak
2. Penis berlubang : [ ]ya [ ]tidak
Kelamin perempuan
1. Introitus vagina : [ ]ada [ ]tidak ada
2. Orifisium uretra : [ ]ada [ ]tidak ada
3. Labio mayora & labio minora : [ ]normal [ ]abnormal
Anus
1. Lubang anus : [ ]ada [ ]tidak ada
Tungkai dan kaki
1. Gerakan normal : [ ]aktif [ ]pasif [ ]tidak ada
2. Normal/tidak normal : [ ]normal [ ]tidak normal
3. Jumlah jari
: ................................................................................
Punggung
1. Pembengkakan/ada cekungan : [ ]ada [ ]tidak ada
Kulit
1. Verniks kaseosa : [ ]ada [ ]tidak ada
2. Warna : .........................................................................
............................................................
3. Pembengkakkan/bercak hitam :
.....................................................................................................................................
4. Tanda lahir :
.....................................................................................................................................

b. Refleks
 Reflek moro :
.....................................................................................................................................
 Reflek rooting :
.....................................................................................................................................
 Reflek walking :
.....................................................................................................................................
 Grahps/plantar : .........................................................................
............................................................
 Reflek sucking :
.....................................................................................................................................
 Reflek tonic neck :
.....................................................................................................................................
BAK : sudah / belum tanggal : ................ pukul : ..........
BAB : sudah / belum warna : ..................... tanggal : ................ pukul : ..........
c. Pemeriksaan laboratorium
HB : ................. gr % Gol.darah : .................
Lain-lain : .......................................................................................

II. INTERPRESTASI DATA DASAR


Tanggal: ................................ Pukul: ..................................
Diagnosa: ..........................................................................................................................
..................
1. Data Subjektif :
a. .......................................................................................................................................
b. .......................................................................................................................................
c. .......................................................................................................................................
d. .......................................................................................................................................
e. .......................................................................................................................................
2. Data Objektif :
a. .......................................................................................................................................
b. .......................................................................................................................................
c. .......................................................................................................................................
d. .......................................................................................................................................
III.Masalah Potensial
Tanggal: ................................ Pukul: ..................................
Diagnosa: ........................................................................................................................
...............
3. Data Subjektif :
a. ..................................................................................................................................
b. ..................................................................................................................................
c. ..................................................................................................................................
4. Data Objektif :
a. ..................................................................................................................................
b. ..................................................................................................................................
c. ..................................................................................................................................
d. ..................................................................................................................................
IV. Tindakan / kebutuhan segera
Tanggal: ................................ Pukul: ..................................
Diagnosa: ........................................................................................................................
......................
Tindakan / kebutuhan segera :
1. .........................................................................................................................................
2. ...................................................................................................
......................................

V. INTERVENSI
Tanggal: ................................ Pukul: ..................................
Diagnosa: ............................................................................................................................
..........
a. .........................................................................................................................................
b. .........................................................................................................................................
c. .........................................................................................................................................
d. .........................................................................................................................................
e. .........................................................................................................................................
VI. IMPLEMENTASI
Tanggal: ................................ Pukul: ..................................
a. .......................................................................................................................................
b. .......................................................................................................................................
c. .......................................................................................................................................
d. .......................................................................................................................................
e. .......................................................................................................................................
VII. EVALUASI
Tanggal: ................................ Pukul: ..................................
Diagnosa: ...................................................................................................................................
...........
a. .........................................................................................................................................
b. .........................................................................................................................................
c. .........................................................................................................................................
d. .........................................................................................................................................
e. .........................................................................................................................................

Palangka Raya, ..................................

Mahasiswa

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

Pembimbing Praktik / Lahan Pembimbing Institusi

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

3.2 CATATAN PERKEMBANGAN KN- .....


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

SUBJEKTIF
OBJEKTIF
ANALISA
PENATALAKSANAAN

Palangka Raya,
Mahasiswa

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

Pembimbing Klinik Pembimbing Institusi

Xxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxx
NIP. ……………………. NIDN/NIK………………
BAB IV PEMBAHASAN

4.1. Kehamilan
4.2 Persalinan
Kala I
Kala II
Kala III
Kala IV
4.4 Nifas
4.5 Bayi Baru Lahir
BAB V
KESIMPULAN DAN SARAN

5.1 Kesimpulan
5.2 Saran
DAFTAR PUSTAKA
Lampiran