ASUHAN KEBIDANAN PADA KESEHATAN REPRODUKSI

No. Register :..................................... Tanggal Pengkajian :..........................

Tanggal masuk :..................................... Waktu Pengkajian :..........................
Waktu masuk :..................................... Tempat Pengkajian :..........................

A. DATA SUBJEKTIF
1. Identitas Pasien
Nama : .................................... Nama : .....................................
Umur : .................................... Umur : .....................................
Pekerjaan : .................................... Pekerjaan : .....................................
Agama : .................................... Agama : .....................................
Pendidikan : .................................... Pendidikan : .....................................
Suku / bangsa: ................................... Suku / bangsa : .....................................
Alamat : .................................... Alamat : .....................................
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No. HP : .................................... No. HP : .....................................

2. Alasan Kunjungan
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3. Keluhan Utama
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4. Riwayat Perkawinan
Perkawinan ke ............................. Menikah sejak umur.........................................
Lama perkawinan......................... Status perkawinan............................................

5. Riwayat Haid
Manarche : .......... Tahun Banyaknya darah: ........ Ganti pembalut/ Hari
Siklus haid : .......... Hari Konsistensi : ...........................................
Lama : .......... Hari Disminorhoe : ............................................
HPHT : ........................... Flour Albus : ............................................

6. Riwayat Kehamilan
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7. Riwayat Kontrasepsi yang Digunakan

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8. Riwayat Kesehatan
a. Riwayat Kesehatan Dahulu………………………………………………………
Menurun : ................................................................................................................
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Menular : .................................................................................................................
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Menahun : ...............................................................................................................
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b. Riwayat Kesehatan Sekarang…………………………………………………….
Menurun : ...............................................................................................................
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Menular : .................................................................................................................
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Menahun : ...............................................................................................................
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c. Riwayat Kesehatan Keluarga…………………………………………………….
Menurun : ...............................................................................................................
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Menular : .................................................................................................................
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Menahun : ...............................................................................................................
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d. Riwayat Penyakit Ginekologi
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9. Pola Kebutuhan Sehari-hari

a. Nutrisi
Makan Teratur/ Tidak Teratur… kali/hari
Konsumsi air putih ± …… kali
Tidak / Ada masalah
b. Eliminasi
BAB … kali/hari
BAK …… kali/hari
Tidak / Ada masalah
c. Istirahat
Tidur siang/ Tidak tidur siang ± …… jam
Tidur malam ± …… jam
Tidak / Ada masalah
d. Aktivitas
Beraktivitas dengan baik, normal / tidak ………………………………………..
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e. Personal Hygiene
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f. Pola Seksual
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10. Data Psiko Sosial Spiritual

Pengetahuan Ibu tentang gangguan/penyakit yang diderita saat ini...............................
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Pengetahuan Ibu tentang Kesehatan Reproduksi ..........................................................
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Dukungan Suami/Keluarga ............................................................................................
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Ketaatan ibu beribadah : ........................................................................................
Ibu tinggal bersama : .........................................................................................
Latar belakang sosial budaya : ......................................................................................
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B. DATA OBJEKTIF
1. Pemeriksaan Umum
Keadaan umum : Baik/ Cukup Baik/ Buruk
Kesadaran : Compomentis/
TTV : Tekanan Darah : ........... mmHg Suhu : .......... oC
Nadi : ........... x/menit Pernapasan : .......... x/menit
BB : ........ Kg
TB : ........ cm
LILA : ……. cm

2. Pemeriksaan Fisik
a. Kepala
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b. Muka
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c. Mata
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d. Hidung
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e. Telinga
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f. Mulut
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g. Leher
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h. Dada
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i. Payudara
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j. Abdomen
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k. Genetalia Luar
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l. Pemeriksaan Dalam/Ginekologis
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m. Ekstremitas
1) Atas : .............................................................................................................
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2) Bawah : ............................................................................................................
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3. Pemeriksaan Penunjang
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C. ANALISA DATA
Tanggal : ............................................. Jam : ...................................
1. Diagnosa Kebidanan
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2. Masalah
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3. Kebutuhan
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D. PENATALAKSANAAN
Tanggal : ............................................. Jam : ....................................
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CATATAN PERKEMBANGAN KESEHATAN REPRODUKSI

Tgl : .................................................. Jam : ...................................................

DATA SUBJEKTIF
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DATA OBJEKTIF
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ANALISA DATA
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PENATALAKSANAAN
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