YAYASAN MARANATHA

NUSA TENGGARA TIMUR

SEKOLAH TINGGI ILMU KESEHATAN MARANATHA
Jl. KAMP. BAJAWA NASIPANAF - BAUMATA BARAT–KAB. KUPANG
Telp/Fax : 0380 – 8552971 ; admin@stikesmaranathakupang.ac.id
Website : http//www.stikesmaranathakupang.ac.id

ASUHAN KEBIDANAN PADA AKSEPTOR KELUARGA BERENCANA

P ….. A ….. AH …..

PENGKAJIAN
No registrasi : ………………….
Tanggal/Jam Pengkajian : ............................
Oleh Mahasiswa : ............................
No.MR/Reg : ............................

BIODATA
Nama isteri : ………………. Nama Suami : …………………………...
Umur : ……………… Umur : …………………………...
Agama : ......................... Agama : .........................................
Suku/Bangsa : ......................... Suku/Bangsa : .........................................
Pendidikan : ......................... Pendidikan : .........................................
Pekerjaan : ......................... Pekerjaan : .........................................
Penghasilan : ......................... Penghasilan : .........................................
Alamat Kantor : ......................... Alamat Kantor : .........................................
Alamat Rumah : ......................... Alamat Rumah : .........................................

I. DATA SUBYEKTIF
Keluhan Utama : ...........................................................................................................
...........................................................................................................

RIWAYAT - RIWAYAT
1. Riwayat Haid
 Menarche : .............................................................................
 Siklus : .............................................................................
 Lamanya darah : .............................................................................
 Sifat Darah : .............................................................................
 Nyeri Haid : .............................................................................
 HPHT : ................................
2. Riwayat Perkawinan
 Status Perkawinan : ...............................................
 Lamanya Kawin : ...............................................
 Umur pada saat kawin pertama : ...............................................
 Berapa Kali Kawin : ...............................................
3. Riwayat Penyakit Sebelumnya
 Hepatitis : ...............................................
 Hipertensi : ...............................................
 Jantung : ...............................................
 Diabetes meletus : ...............................................
 Perdarahan pervagina diluar siklus haid : ..............................................
 Keputihan yang lama : ...............................................

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  Tumor payudara : ...............................................
 Tumor Rahim : ...............................................
4. Riwayat Keluarga Berencana yang lalu
 KB yang pernah dipergunakan : ...............................................
 Lamanya : ...............................................
 Efek Samping : ...............................................
 Alasan Berhenti : ...............................................
5. Riwayat Kesehatan Keluarga dan Penyakit Keturunan
 Apakah ada Keluarga yang menderita penyakit kronis : .........................
 Apakah ada Keluarga yang menderita penyakit menular : .........................
 Apakah ada Keluarga yang keturunan kembar : .........................
6. Riwayat Latar Belakang Budaya
 Pantang Makanan : ............................
 Pantang berhubungan seksual : ............................

7. Riwayat Seksual
 Apakah ada perubahan pola berhubungan seksual : ..................................
...................................................................................................................

8. Riwayat Diet / Makanan

 Jenis Makanan Pokok : .........................................................
 Porsinya : .........................................................
 Frekuensi makanan : .........................................................
 Lauk Pauk : .........................................................
 Minum Susu dan Air putih : .........................................................
9. Riwayat Pola Eliminasi
 BAK
Frekuensi : .........................................................
Warna bau & Konsistensi : .........................................................
Keluhan : .........................................................
BAB
Frekuensi : .........................................................
Warna,bau & Konsistensi : .........................................................
Keluhan : .........................................................
10. Kebiasaan diri : .........................................................
Mandi : .........................................................
Sikat gigi : .........................................................
Cuci rambut : .........................................................

2. JUMLAH ANAK
Jumlah Anak Hidup Umur Anak Saat
No Abortus Menyusui Ket.
L P Ini

3. Status Peserta KB Saat Ini : …………………………………………………………

4. Jenis Alat Kontrasepsi Yang Diinginkan Saat Ini : .................................................
 IUD  PIL  MOW
 SUNTIKAN  IMPLAN  MOP
 KONDOM  DLL

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II. DATA OBYEKTIF
1. Pemeriksaan Umum
 Keadaan umum : …………………………………………………………………
 Kesadaran : …………………………………………………………………
 Tanda Vital
- Suhu : …..….. °C Pernapasan : ….... x per menit
- Tek. Darah : .…/….. mmHg Nadi : ….... x per menit
 TB : ................................... cm
 BB : ................................... kg

2. Pemeriksaan Fisik
 Inspeksi dan Palpasi
- Kepala : .........................................................
- Rambut : .........................................................
- Wajah
 Bentuk : .........................................................
 Pucat : .........................................................
 Cloasma gravidarum : .........................................................
 Oedema : .........................................................
- Mata
 Conjungtiva : .........................................................
 Sklera : .........................................................
 Oedema : .........................................................
- Telinga
 Simetris : .........................................................
 Serumen : .........................................................

- Hidung, Mulut dan Gigi

 Polip : .........................................................
 Sekret : .........................................................
 Karies : .........................................................
 Stomatitis : .........................................................
 Gingivitis : .........................................................
- Leher
 Adakah pembesaran kelenjar limfe : ............................
 Adakah pembesaran kelenjar thyroid : ............................
 Adakah pembesaran vena jungularis : ............................

- Dada
 Mamae : .........................................................
- Perut
 Pembesaran/Massa : .........................................................
 Nyeri tekan : .........................................................
 Bekas luka operasi : .........................................................
- Ekstremitas Atas dan Bawah
 Bentuk : .........................................................
 Varises : .........................................................
 Oedema : .........................................................

 Vulva vagina
 Varises : .........................................................
 Kemerahan : .........................................................
 Oedema : .........................................................
 Keputihan : .........................................................

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  Pemeriksaan Dalam
 Nyeri goyang portio : …………………………………………………………………
 Posisi rahim : …………………………………………………………………
 Tumor : …………………………………………………………………
 Keputihan : …………………………………………………………………

 Inspekulo
Portio
 Erosi : ...................................................................
 Lesi : ...................................................................
 Keputihan : ...................................................................
 Tumor / polip : ...................................................................
 Pengeluaran lain : ...................................................................

 Pemeriksaan Laboratorium
 PST : ...................................................................
 HB : ...................................................................

III. ANALISA DATA

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IV. PENATALAKSANAAN (Perencanaan, Pelaksanaan dan Evaluasi)
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Pebimbing Lahan Praktik/CI Mahasiswa

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Mengetahui
Pembimbing Institusi/CT

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