YAYASAN WAHANA BHAKTI KARYA HUSADA

AKADEMI KEBIDANAN
” RSPAD GATOT SOEBROTO”
Jl. Dr. Abdul Rachman Saleh No.24 Jakarta Pusat (10410) Telp.(021) 3441008 Psw.2241 Fax.3454373

MANAJEMEN ASUHAN KEBIDANAN PADA AKSEPTOR KB

No. Registrasi : ......................................................................................................................
Nama Pengkaji : ......................................................................................................................
Hari / Tanggal : ......................................................................................................................
Waktu Pengkajian : ......................................................................................................................
Tempat Pengkajian : .....................................................................................................................

I. PENGKAJIAN

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

B. ANAMNESA (Data Subyektif) pada tanggal : …………………. Pukul : …………………..

1. Keluhan utama pada waktu masuk :

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

2. 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

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 : …………………………………
h. Keputihan : ..............................................

4. Riwayat Obstetri
a. Jumlah anak lahir hidup : .............................................................................
b. Jumlah anak meninggal : ……………………………………………………….
c. Jenis kelamin anak yang dilahirkan : ……………………………………………………….
d. Persalinan terakhir : .............................................................................

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 e. Jenis Persalinan terakhir : .............................................................................
f. Komplikasi : .............................................................................
g. Keadaan nifas terakhir : .............................................................................

5. Riwayat Keluarga Berencana

Macam peserta keluarga berencana :
a. Baru : ............................................................................
b. Setelah bersalin / keguguran : ............................................................................
c. Pernah pakai alat KB : ............................................................................
d. Cara KB terakhir : ............................................................................
e. Keluhan selama menggunakan KB : ............................................................................

6. Riwayat Penyakit yang Lalu dan Sekarang

a. Hepatitis : ...........................................................................
b. Diabetes Melitus : ...........................................................................
c. Penyakit jantung : ...........................................................................
d. Kelainan pembekuan darah : ...........................................................................
e. Radang : ...........................................................................
f. Hipertensi : ..........................................................................
g. Adneksitis : ..........................................................................
h. Endometriosis : ..........................................................................

7. Ekstremitas
a. Udem : ..........................................................................
b. Varices : ..........................................................................

C. PEMERIKSAAN FISIK (Data Obyektif)

1. Pemeriksaan Umum :
a. Keadaan umum : ...................................................................................................
b. Kesadaran : ...................................................................................................
c. Tekanan Darah : ………………………………………………………………………..
d. Suhu : ………………………………………………………………………..
e. Nadi : ………………………………………………………………………..
f. Respirasi : ………………………………………………………………………..
g. Tinggi badan : ...................................................................................................
h. Berat badan : ………………………………………………………………………..

2. Pemeriksaan Sistematis ( Umum ) :

a. Kepala
1) Muka : ………………………………………………………………………..
2) Mata : ………………………………………………………………………..
a) Conjungtiva : ………………………………………………………………………..
b) Sklera : ………………………………………………………………………..

b. Leher
1) Kel. Gondok
(Thyroid) : ………………………………………………………………………..
2) Tumor : ………………………………………………………………………..

c. Dada dan axilla (Ketiak)

1) Mammae
a) Pembengkakan : ………………………………………………………………………..
b) Tumor : ………………………………………………………………………..
c) Simetris : ………………………………………………………………………..
2) Axilla :
a) Tumor : ………………………………………………………………………..
b) Nyeri tekan : ………………………………………………………………………..

d. Perut :

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 1) Jaringan parut : ...................................................................................................
2) Palpasi : ...................................................................................................

e. Anogenital :
1) Vulva / vagina
a) Perdarahan : ...................................................................................................
b) Fluor albus : ...................................................................................................

2) Inspekulo
a) Portio : ...................................................................................................
b) Erosi : ...................................................................................................
c) Tanda-tanda radang : ..................................................................................................

3) Periksa Dalam
a) Vagina : ..................................................................................................
b) Portio : ..................................................................................................
c) Uterus : ..................................................................................................
- Posisi : ..................................................................................................
- Nyeri tekan/goyang: ..................................................................................................

3. PEMERIKSAAN LABORATORIUM

Tanggal Pemeriksaan : .............................................

Darah : Hb : ……………. gr % Ht : ........................... gr %
Gol Darah : ……………… ……………
Urine : Protein : ……………. Reduksi : ………………
Pemeriksaan Penunjang Lain : ……………………………………………………………………………….

II. ANALISA
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III. PLANNING (RENCANA, IMPLEMENTASI, EVALUASI)

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Jakarta, ……………………….

Mengetahui : PENOLONG
PEMBIMBING LAHAN

(………………………………) (…………………………………)

Mengetahui :

PEMBIMBING AKADEMIK

(………………………………..)