ASUHAN KEBIDANAN

PADA Ny. ..... Usia ...... dengan akseptor KB ............................

Tanggal Pengkajian : ………………………….

Tempat Pengkajian : …………………………..
Oleh : …………………………..
No. Register : …………………………..

DATA SUBJEKTIF (S)

1. Biodata : ........................................................................................................
Nama ibu : .................................................................................................. ....
Umur : ........................................................................................................
Pendidikan : ........................................................................................................
Pekerjaan : ........................................................................................................
Agama : ........................................................................................................
Alamat : ........................................................................................................
2. Keluhan Utama : ........................................................................................................
...............................................................................................................................................
3. Riwayat Kesehatan : ........................................................................................................
....................................................................................................................................................
............................................................ ...............................................................................
4. Riwayat Menstruasi
- Menarche : ........................................................................................................
- Lama : ........................................................................................................
- Jumlah : ........................................................................................................
- Fluor Albus : ........................................................................................................
- Dysmenore : ........................................................................................................
- Siklus : ........................................................................................................
- Keluhan : ........................................................................................................
5. Riwayat Perkawinan.
- Status Perkawinan : ........................................................................................................
- Lamanya : ........................................................................................................ ....
- Usia waktu nikah : ........................................................................................................
6. Riwayat KB
- Kontrasepsi yang pernah digunakan : ..........................................................................
- Lama menggunakan : .........................................................................
- Masalah (jika ganti cara) : .........................................................................
7. Pemenuhan Kebutuhan Sehari – hari .
- Nutrisi : .............................................................................................
- Eliminasi : ..................................................................................................
 - Personal Hygiene : .............................................................................................
- Aktivitas : ..............................................................................................
- Hubungan Seksual (jika ada masalah) :
8. Data Psikologi dan Budaya
- Dukungan Suami : ..............................................................................................
........................................................................................................ ................................
- Budaya tentang KB : .............................................................................................
........................................................................................................ ..................................

DATA OBJEKTIF (O)

1. Pemeriksaan umum.
- K/U : .................................. - RR : .................................
- Kesadaran : .................................. - Suhu : .................................
- TD : .................................. - BB : .................................
- Nadi : ...................................
2. Pemeriksaan Fisik.
- Kepala / Rambut : ..............................................................................................
- Muka / mata : ..............................................................................................
- Hidung : ..............................................................................................
- Mulut / Gigi : ..............................................................................................
- Dada : ..............................................................................................
- Abdomen : ..............................................................................................
- Genitalia dan anus*) : ..............................................................................................
- Extremitas : ..............................................................................................
*) Jika diperlukan
3. Pemeriksaan Dalam (VT) *) bagi pengguna IUD/AKDR
Hasil : ..............................................................................................
..............................................................................................
..............................................................................................

ANALISA DATA (A)

1. Diagnosa : ..............................................................................................
..............................................................................................
2. Masalah : ..............................................................................................
..............................................................................................
3. Kebutuhan :
- .............................................................................................. .............................................
- .............................................................................................. ........................................
- .............................................................................................. ............................................
PENATALAKSANAAN (P)

No. IMPLEMENTASI EVALUASI/HASIL

*)Jika penatalaksanaannya banyak, silahkan membuat tabel lain pada lembar baru

Mahasiswa,

( ........................................................ )
NPM.

Mengetahui,

Dosen Pembimbing, Bidan Pembimbing,

( ..................................................... ) ( ..................................................... )
NIK. NIP.