Format Asuhan Kebidanan Pada Ibu Hamil
Format Asuhan Kebidanan Pada Ibu Hamil
I. PENGKAJIAN
Tanggal : Jam :
No. RM :
Nama : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat : Alamat :
Cara masuk :
Datang Sendiri Rujukan dari :
Diagnose :
A. DATA SUBYEKTIF
1. Keluhan
utama : ...................................................................................................................................
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.............
2. Riwayat menstruasi
Usia manarche :
Jumlah darah haid :
HPHT :
Keluhan saat haid :
Lama haid :
Flour albus :
TP :
Keluhan haid :
Disminorhoe Spoting Menorrhagia Premenstrual syndrome
Dll..............
3. Riwayat hamil ini
Hamil muda :
Mual Muntah Perdarahan Lain-lain(isi sesuai keluhan)
Hamil tua :
Pusing Sakit Kepala Perdarahan Lain-lain(isi sesuai keluhan)
Riwayat imunisasi : TT1 TT2
Gerakan janin pertama :..................bulan
Gerakan janin
terakhir ..............................................................................................................................
.........
Tanda bahaya dan penyulit
kehamilan .........................................................................................................................
..............
Obat/jamu yang pernah dan sedang di
konsumsi :..........................................................................................................................
............
Keluhan BAK :.................. Keluhan BAB :........................
Kekhawatiran
khusus : ............................................................................................................................
....
6. Riwayat penyakit keluarga (Ayah, Ibu, Mertua) yang pernah menderita sakit :
................................................................................................................................................
B. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum : Kesadaran :
BB/TB : Tekanan Darah:
Nadi : Suhu :
Pernafasan :
2. Pemeriksaan Fisik
- Mata : Konjungtiva : anemis/tidak Selera : Ikterik/tidak
Pandangan Kabur Adanya pemandangan dua
- Rahang, gigi, gusi: normal/tidak, gusi berdaarah/tidak
- Leher : adanya pembesaran vena jugularis / tidak, adanya pembesaran kelenjar
thyroid/tidak.
- Dada : aerola hiperpigmentasi Tumor Kolostrum
Puting susu menonjol/masuk ke dalam
- Axilla :
- Sistem respiratori : dispneu tachipneu wheezing batuk
- Sistem kardio : Nyeri dada murmur palpitasi
- Pinggang :nyeri/tidak, skoliosis, lordosis, kiposis(coret yang tidak perlu)
- Ekstrimitas atas dan bawah: tungkai simetris/asimetris oedema
Reflek patella varises
3. Pemeriksaan khusus
a. Abdomen
Inspeksi membesar dengan arah memanjang melebur
Pelebur vena linea alba linea agra strie livide
Strie albican luka bekas operasi lain-lain
Palpasi : TFU : .................cm, letak punggung :....................
Presentasi : ................................ penurun kepala : .....................................
TBJ : ...........................gram
Auskultasi : BJJ................x/mnt, reguler / irreguler
His/kontraksi : ......................
4. Pemeriksaan laboratorium :
- Laboratorium lengkap.
- CTG : janin................reaktif/tidak
- USG : ...........................................
- Foto thorak : ............................................
- EKG : ............................................
D. PENATALAKSANAAN
Tanggal : ....................................................... Jam : ..........................
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Kediri,............................
Pembimbing Praktik Mahasiswa
.................................................... ......................................................
NIP. NIM.
Dosen Pembimbing
....................................................
NIP.