FAKULTAS KEPERAWATAN DAN KEBIDANAN

PROGAM STUDI KEBIDANAN UNIVERSITAS BINAWAN

Jalan Kalibata Raya No. 25 – 30 Jakarta Timur 13630

Nama Mahasiswi : ...........................................................

NIM : ...........................................................
Lahan Praktik : ...........................................................
Tanggal Pengkajian : ...........................................................

ASUHAN KEBIDANAN PADA AKSEPTOR KB

DI .............................................
TANGGAL .............................
NO REGISTER :
TANGGAL / JAM MASUK :
RAWAT DI RUANG :

PENGKAJIAN DATA SUBYEKTIF

A. IDENTITAS
Nama : .......................................... Nama Suami : ....................................
Umur : .......................................... Umur : ....................................
Suku : .......................................... Suku : ....................................
Agama : .......................................... Agama : ....................................
Pendidikan : .......................................... Pendidikan : ....................................
Pekerjaan : .......................................... Pekerjaan : ....................................
Alamat Rumah : .......................................... Alamat Rumah : ...................................
Alamat Kantor : .......................................... Alamat Kantor : ....................................
B. ANAMNESA
1. Kunjungan saat ini :
 Kunjungan pertama
 Kunjungan ulang
Keluhan
.........................................................................................................................................
.........................................................................................................................................
2. Riwayat Perkawinan
Kawin ....... kali, kawin pertama umur ........ tahun,dengan suami sekarang ....... tahun
3. Riwayat Menstruasi
Menarce umur ....... tahun, Siklus ........ hari, teratur/tidak, Lamanya ........ hari, Sifat
darah : encer / beku , Bau .................. , Dismenore : ya / tidak, Banyaknya .......... cc
4. Riwayat Kehamilan, Persalinan, Nifas yang lalu
P ................... Ab ....................... Ah .....................
Hamil Persalinan Nifas
 Tgl Jenis Komplikasi Jenis
lahi Umur Persalin Penolo Kela BB Lakt Kompli
r kehamilan an ng Ibu Bayi min Lahir asi kasi
                     
                     
                     
                     
                     

5. Pengetahuan ibu tentang kontrasepsi yang dipakai

........................................................................................................................................
6. Dukungan suami / keluarga
........................................................................................................................................

PENGKAJIAN DATA OBYEKTIF

C. PEMERIKSAAN
1. Keadaan umum .................... Kesadaran ..................... Keadaan Emosional ................
2. Tanda Vital
Tekanan Darah : ..................... Nadi : ................. Suhu : ................ Rr : ......................
3. Tinggi badan : ................. kg, Berat badan : ................... cm , Lila : ...................... cm
4. Pemeriksaa Fisik
a. Kepala dan leher
Edema wajah : ........................................................................................
Cloasma Gravidarum :+/-
Mata
Kelopak mata : ........................................................................................
Konjungtiva : ........................................................................................
Sclera : ........................................................................................
Mulut dan Gigi
Lidah dan Geraham : ........................................................................................
Gigi : ........................................................................................
Kelenjar Tyroid
Pembesaran : ........................................................................................
b. Dada
Jantung : ........................................................................................
Paru : ........................................................................................
Payudara : ........................................................................................
Pembesaran : ........................................................................................
Puting Susu : ........................................................................................
Simetris : ........................................................................................
Benjolan : ........................................................................................
Pengeluaran : ........................................................................................
Rasa nyeri : ........................................................................................
c. Ekstremitas atas
Oedem : ........................................................................................
Kekuatan sendi : ........................................................................................
 Kemerahan : ........................................................................................
Varices : ........................................................................................
d. Abdomen
Bekas luka operasi : ..................................... Pembesaran : ...........................
Benjolan : ........................................................................................
e. Ekstremitas bawah
Oedem : ........................................................................................
Kekuatan sendi : ........................................................................................
Kemerahan : ........................................................................................
Varices : ........................................................................................
Reflex : ........................................................................................
f. Genetalia Luar
Varices : ........................................................................................
Bekas luka : ........................................................................................
Pengeluaran : ........................................................................................
g. Anus
Haemoroid : ........................................................................................
Pemeriksaan dalam : ........................................................................................

5. Riwayat Kontrasepsi yang digunakan

Mulai Memakai Berhenti / Ganti

Jenis
Kontraseps
No i Tanggal Oleh Tempat Keluhan Tanggal Oleh Tempat Keluhan
                   
                   
                   
                   

6. Riwayat kesehatan
a. Penyakit yang pernah / sedang
diderita ...................................................................................................................
..............
b. Penyakit yang pernah / sedang diderita keluarga
.................................................................................................................................
c. Riwayat penyakit
Ginekologi ..............................................................................................................
...................
7. Pola pemenuhan kebutuhan sehari – hari
a. Nutrisi
- Frekuensi makan : ............................................................................
- Jenis makanan : ............................................................................
- Pantang dalam makanan : ............................................................................
- Minuman ( Jumlah/Jenis) : ............................................................................
- Keluhan : ............................................................................
b. Eliminasi
BAK
 Frekuensi : ....................................................................................................
Warna : ....................................................................................................
Bau : ....................................................................................................
BAB
Frekuensi : ....................................................................................................
Warna : ....................................................................................................
Bau : ....................................................................................................
Konsistensi : ....................................................................................................
c. Pola Aktivitas
Kegiatan sehari : ....................................................................................................
Istirahat dan Tidur : ................................................................................................
d. Seksualitas
Frekuensi : ....................................................................................................
Keluhan : ....................................................................................................
e. Personal Hygiene
Kebiasaan mandi : ................................................................
Kebiasaan membersihkan alat kelamin : ................................................................
Kebiasaan mengganiti pakaian dalam : ................................................................
f. Keadaan Psiko sosial spiritual : ................................................................
g. Pemeriksaan Penunjang : ................................................................

ASSESMENT

Diagnosa kebidanan ( disertai dengan data focus dan analisa data)

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Masalah
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Kebutuhan
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Diagnosa potensial (disertai dengan data focus dan analisa data)
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Masalah Potensial
......................................................................................................................................................
Kebutuhan tindakan segera berdasarkan kondisi klien
Mandiri
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Kolaborasi
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Rujukan
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PLANNING

Tanggal .......................................................... Jam ....................................................................

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