Politeknik Kesehatan Kementerian Kesehatan Jakarta 1

Jurusan Kebidanan

Nama Mahasiswa :
NIM :
Tingkat :
Tempat Praktek :

FORMAT PENGKAJIAN
ASUHAN KEGAWATDARURATAN MATERNAL
Tempat : ................................................ Tanggal / Jam : ..............................................
A. DATA SUBJEKTIF
I. BIODATA

KLIEN SUAMI

Nama : .......................................... Nama : ............................................

Umur : .......................................... Umur : ............................................
Agama : .......................................... Agama : ............................................
Suku/Bangsa : ......................................... Suku/Bangsa : ............................................
Pendidikan : .......................................... Pendidikan : ............................................
Pekerjaan : .......................................... Pekerjaan : ............................................
Alamat/ Tlp : ..................................................................................................................................
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1. Alasan datang
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2. Keluhan Utama
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3. Riwayat Menstruasi
 Menarche : Umur :....................................................................................
 Menstruasi : Siklus : ...................................................................................
Lama : ...................................................................................
Banyak : ...................................................................................
Teratur / Tidak: .................................................................................
Sifat Darah : ...................................................................................
Dismenore : ...................................................................................
 HPHT : ................................................................................................
 Taksiran Persalinan : ................................................................................................
Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan

4. Riwayat Kehamilan dan Persalinan yang lalu

Anak Tahun Usia Jenis Penolong Komplikasi Anak Nifas

Ke Lahir Kehamilan Persalinan JK BB PB ASI Penyulit

5. Riwayat Kehamilan Ini G ............... P .................. A ...................

A. Hamil Muda
 Keluhan : .............................................................................................................
 ANC di : ............................................... Oleh : ..................................................
 Frekuensi ANC: ............. Kali, Teratur / Tidak Teratur
 Imunisasi TT : .............................................................................................................
B. Hamil Tua
 Keluhan : .............................................................................................................
 ANC di : .................................................. Oleh : ...............................................
 Frekuensi ANC: ............. Kali, Teratur / Tidak Teratur
 Imunisasi TT : .............................................................................................................

6. Riwayat Penyakit Sistemik

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7. Riwayat Penyakit yang lalu / Riwayat Operasi
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8. Riwayat Alergi Obat
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9. Riwayat Kebiasaan
Makan / Minum :.......................................................................................................................
Eliminasi : ......................................................................................................................

II. DATA OBJEKTIF

A. PEMERIKSAAN FISIK
1. Kesadaran Umum : ................................................................................................
2. Keadaan Umum : ................................................................................................
3. Tanda-tanda vital : TD ............................ mmHg, Nadi ..........................x/menit
Suhu .........................◦C, Pernafasan ....................... x/menit
4. BB : ................................kg, TB : ...............................cm
Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan

Kenaikan BB selama Hamil : ....................Kg

5. Muka : Pucat : Iya / Tidak Oedema : Iya / Tidak
6. Mata : Conjungtiva : Anemis / Tidak Sklera : Ikterik / Tidak
7. Payudara
Mamae : Membesar .................................. Simetris..............................
Benjolan/Tumor : ................................................................................................
Areola : Hyperpigmentasi....................................................................
Papila Mammae : Menonjol ...............................................................................
Pengeluaran Colostrum/ ASI : ...................................................................................
8. Abdomen
Inspeksi
Membesar dengan arah : Memanjang / Melintang
Luka Bekas Operasi : ................................................................................................
Gerakan Janin : ................................................................................................
Palpasi
TFU (Mc.Donald) : ............. cm
Leopold I : TFU .......................................................................................
Pada fundus uteri teraba.........................................................
Leopold II : Sebelah Kanan .......................................................................
Sebelah Kiri ...........................................................................
Leopold III : Bagian terendah janin teraba .................................................
Auskultasi
DJJ : Frekuensi : ...........x/menit, Intonasi : ............Teratur / Tidak
Punctum Maksimum : ................................................................................................
Kontraksi Uterus : His .........................................................................................
9. Ekstremitas atas dan bawah
Atas : Simetris Ya/Tidak Oedema : Ya /Tidak
Bawah : Simetris Ya/Tidak Oedema : Ya /Tidak Varices : Ya /Tidak
Reflek patella : Kanan : ................................... Kiri : ...................................
10. Anogenital
Vulva / vagina : ................................................................................................
Portio : Arah : ......................................................................
Konsistensi : ......................................................................
Penipisan : ......................................................................
Pembukaan : ......................................................................
Ketuban :
Bagian Terendah janin:
Penunjuk :
Penurunan :
Molase/Penyusupan :
Bagian lain janin :

B. PEMERIKSAAN PENUNJANG
1. Pemeriksaan urine
Protein : .........................................
Reduksi : .........................................
Utobilin : ........................................
Bilirubin : ........................................
Politeknik Kesehatan Kementerian Kesehatan Jakarta 1
Jurusan Kebidanan

2. Pemeriksaan darah
Hb : .........................................
Golongan darah : .........................................
3. Pemeriksaan Pap Smear
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4. Pemeriksaan lain-lain bila diperlukan
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III. DIAGNOSA
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IV. PENATALAKSANAAN
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Jakarta, ...............................
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