MANAJEMEN ASUHAN KEBIDANAN REMAJA PUTRI

PADA Nn “……………………….........” DENGAN………….....................

DI……...........................................................................................................

A. IDENTITAS/BIODATA

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

Umur :...........................................................................................

Agama :...........................................................................................

Suku/Bangsa :...........................................................................................

Pendidikan :...........................................................................................

Pekerjaan :...........................................................................................

Alamat :...........................................................................................

No.HP/Telp :...........................................................................................

............................................................................................

Nama Ibu :................................................ Nama Ayah :........................

Umur :................................................ Umur :........................

Agama :................................................ Agama :........................

Suku/Bangsa:................................................ Suku/Bangsa :........................

Pendidikan :................................................ Pendidikan :........................

Pekerjaan :................................................ Pekerjaan :........................

Alamat :................................................ Alamat :........................

 No.HP/Telp :................................................ No.HP/Telp :........................

B. DATA SUBJKTIF

Hari/tanggal : Pukul :

1. Alasan Kunjungan :..........................................................................

2. Keluhan-keluhan :..........................................................................

3. Riwayat Menstruasi :..........................................................................

Menarche :..........................................................................

Siklus :..........................................................................

Banyaknya :..........................................................................

Dismenorhea :..........................................................................

Teratur/Tidak :..........................................................................

Lamanya :..........................................................................

Sifat Darah :..........................................................................

Haid Terakhir :..........................................................................

4. Keluhan yang dirasakan

a. Keputihan :.................................................................

b. Nyeri Payudara :.................................................................

c. Masalah didaerah kemaluan :.................................................................

d. Lain-lain :.................................................................

5. Pola pemenuhan kebutuhan nutrisi, eliminasi dan aktifitas sehari-hari

 Diet/pola nutrisi

Jenis Makanan :.................................................................

 Frekuensi :.................................................................

Jenis Minuman :.................................................................

Frekuensi :.................................................................

 Pola Eliminasi

BAB

Frekuensi :............................................................................

Warna :............................................................................

Bau :............................................................................

Konsistensi :............................................................................

BAK

Frekuensi :............................................................................

Warna :............................................................................

Bau :............................................................................

Konsistensi :............................................................................

 Aktivitas Sehari-hari

- Istirahat tidur

Siang :............................................................................

Malam :............................................................................

Gangguan pola tidur:............................................................................

Pekerjaan :............................................................................

 Personal Hygiene

Mandi :............................................................................
 Mengganti pakaian dalam.....................................................................

6. Riwayat penyakit sistemik

Kelainan Jantung :............................................................................

Kelainan Ginjal :............................................................................

Asma/TB Paru :............................................................................

Hepatitis :............................................................................

DM :............................................................................

Hipertensi :............................................................................

Epilepsi :............................................................................

Alergi :............................................................................

7. Riwayat penyakit keluarga

Kelainan jantung :............................................................................

Kelainan ginjal :............................................................................

Asma/TB Paru :............................................................................

DM :............................................................................

Hipertensi :............................................................................

Epilepsi :............................................................................

Alergi :............................................................................

8. Riwayat Sosial

Kegiatan diluar sekolah :.......................................

Kegiatan dirumah :.......................................

 Hubungan dengan anggota keluarga dirumah :.......................................

Hubungan dengan teman sebaya :.......................................

Hubungan dengan lingkungan luar :.......................................

Aktifitas religi :.......................................

9. Masalah remaja

Pacaran :.......................................................

Aktifitas seksualitas (Masturbasi) :.......................................................

NAPZA dan alkohol :.......................................................

Kebiasaan Merokok :.......................................................

Penggunaan alat kontrasepsi :.......................................................

Akses pornografi (film, gambar) :.......................................................

10. Sumber informasi kesehatan reproduksi :.......................................................

C. DATA SUBJEKTIF

1. Pemeriksaan Umum

a. Keadaan Umum :............................................................................

b. Tingkat kesadaran :............................................................................

c. Keadaan emosional :............................................................................

d. Pemeriksaan tanda-tanda vital

Tekanan darah :.................................. Nadi :...........................

Respirasi :.................................. Suhu badan :...........................

e. Antropometri

LILA :...........................................................................................
 Tinggi badan :...........................................................................................

Berat badan :...........................................................................................

2. Pemeriksaan Head To Toe

a. Kepala :....................................................................................................

b. Wajah :....................................................................................................

c. Mata :....................................................................................................

d. Telinga :....................................................................................................

e. Hidung :....................................................................................................

f. Mulut :....................................................................................................

g. Leher :....................................................................................................

Pembesaran kelenjar Tiroid :...................................................................

Pembesaran Kelenjar Limfe :...................................................................

Pembesaran Vena Jugularis :...................................................................

h. Dada

Payudara :..........................................................................

Benjolan :..........................................................................

Putting susu :..........................................................................

Areola :..........................................................................

Nyeri Tekanan :..........................................................................

i. Abdomen

Bekas luka operasi :..........................................................................

Pembesaran perut :..........................................................................

 Bentuk perut :..........................................................................

j. Pemeriksaan Genetalia :..........................................................................

k. Anus :..........................................................................

l. Ekstremitas

Pucat telapak tangan dan ujung jari :.......................................................

Oedema tangan dan kaki :.......................................................

Betis merah/keras, varises :.......................................................

Refleks patella kanan/kiri :.......................................................

h. Pemeriksaan Penunjang :.......................................................

D. ASSESMENT

Hari/Tanggal : Pukul :

1. Diagnosa :........................................................................................

2. Masalah :........................................................................................

3. Kebutuhan :........................................................................................

E. PLANNING

Hari/Tanggal : Pukul :

1...............................................................................................................................

2...............................................................................................................................

3...............................................................................................................................

4...............................................................................................................................

F. EVALUASI

Hari/Tanggal : Pukul :
 1...............................................................................................................................

2...............................................................................................................................

3...............................................................................................................................

4. .............................................................................................................................

Palopo, Desember 2021

MENGETAHUI

Preseptor Lahan Preseptor Institusi

(…………………………………..) (…………………………………..)
 PENDOKUMENTASIAN ASUHAN KEBIDANAN MENOPAUSE
PADA NY “…..........” UMUR ……....................................... TAHUN
DENGAN………………...........................................................................
DI……….......................................................................................................

A. IDENTITAS/BIODATA

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

Umur :........................................... Umur :...............................

Agama :........................................... Agama :...............................

Suku/Bangsa :........................................... Suku/Bangsa :...............................

Pendidikan :........................................... Pendidikan :...............................

Pekerjaan :........................................... Pekerjaan :...............................

Alamat :........................................... Alamat :...............................

No.HP/Telp :........................................... No.HP/Telp :...............................

B. DATA SUBJEKTIF

Hari/tanggal : Pukul :

1. Kunjungan Ke :............................................................................

2. Alasan kunjungan ini :............................................................................

3. Keluhan-keluhan :............................................................................

4. Riwayat menstruasi :............................................................................

a. Menstruasi sebelum menopause

Haid pertama umur :............................................................................

Haid terakhir :............................................................................

 Lamanya :............................................................................

Banyaknya :............................................................................

Siklus :............................................................................

Konsistensi :............................................................................

Dismenorhea :............................................................................

b. Gangguan menstruasi

Sejak :............................................................................

Siklus :............................................................................

Banyaknya :............................................................................

Dismenorhea :............................................................................

Teratur/tidak :............................................................................

Lamanya :............................................................................

Sifat darah :............................................................................

c. Menstruasi terakhir :............................................................................

5. Riwayat kehamilan, persalinan dan nifas yang lalu

6. Riwayat kontrasepsi yang pernah digunakan :..................................................

Persalinan Nifas
Umur
No Jenis Penolong Komplikasi
anak UK JK BB PB Laktasi Komplikasi
Persalinan persalinan Ibu Bayi
7. Keluhan yang dirasakan saat ini

Hot Flush :...................................................................

Nyeri perut :...................................................................

Rasa kedinginan :...................................................................

Panas tinggi atau demam :...................................................................

Sakit kepala :...................................................................

Palpitasi :...................................................................

Masalah pada daerah kemaluan

- Vagina kering dan gatal :...................................................................

- Mudah luka :...................................................................

- Keputihan :...................................................................

- Nyeri waktu senggama :...................................................................

- Perdarahan pasca senggama :...................................................................

- Pengeluaran cairan pervaginam:..................................................................

Nyeri sendi :...................................................................

Nyeri otot :...................................................................

Sulit tidur :...................................................................

Pusing :...................................................................

Susah bernafas :...................................................................

8. Gangguan psikologi

Depresi :...................................................................

Kurang percaya diri :...................................................................

 Mudah tersinggung :...................................................................

Sulit berkonsentrasi :...................................................................

Menurunnya daya ingat :...................................................................

9. Diet/Makanan

Makan sehari-hari :...................................................................

Jenis Makanan :...................................................................

Minum :...................................................................

Jenis minuman :...................................................................

10. Pola Eliminasi

BAB :…… Frekuensi :…… Bau :…… Konsistensi :……

BAK :…… Frekuensi :…… Bau :…… Konsistensi :……

11. Aktifitas sehari-hari

Pola istirahat dan tidur

- Tidur malam :...................................................................

- Tidur siang :...................................................................

Gangguan pola tidur :...................................................................

Aktifitas seksualitas :...................................................................

- Seksualitas :...................................................................

- Masalah dalam seksualitas :...................................................................

- Masturbasi :...................................................................

Masalah dalam seksualitas :...................................................................

Pekerjaan :...................................................................
 Masalah dalam pekerjaan :...................................................................

Personal hygiene :...................................................................

- Mandi :...................................................................

- Mengganti pakaian dalam :...................................................................

Obat-obatan yang pernah dikonsumsi:..............................................................

Pemeriksaan payudara sendiri :...................................................................

Olahraga :...................................................................

Binatang peliharaan :...................................................................

12. Riwayat penyakit sistemik

Kelainan Jantung :...................................................................

Kelainan ginjal :...................................................................

Asma/TB Paru :...................................................................

Hepatitis :...................................................................

Diabetes Melitus :...................................................................

Hipertensi :...................................................................

Epilepsi :...................................................................

Alergi :...................................................................

Penyakit kandung empedu :...................................................................

Endometriosis :...................................................................

Kanker :...................................................................

13. Riwayat penyakit keluarga

 Kelainan jantung :...................................................................

Hipertensi :...................................................................

Asma :...................................................................

Gemeli :...................................................................

CA Mamae :...................................................................

Stroke :...................................................................

Osteoporosis :...................................................................

14. Riwayat sosial

Perkawinan :...................................................................

Status perkawinan :...................................................................

Kegiatan diluar rumah :...................................................................

Kegiatan dirumah :...................................................................

Hubungan dengan anggota keluarga di rumah:.................................................

Hubungan dengan teman sebaya :...................................................................

Hubungan dengan lingkungan luar:...................................................................

Aktivitas religi :...................................................................

NAPZA dan alkohol :...................................................................

Kebiasaan merokok

- Frekuensi :...................................................................

- Jumlah :...................................................................

C. DATA OBJEKTIF
1. Keadaan Umum :

2. Tingkat kesadaran :

3. Keadaan emosional :

4. Tanda-tanda vital

- TD :............................. LILA:.....................................

- N :............................. TB :......................................

- P :............................. BB :.....................................

- S :.............................

5. Kepala :............................................................................

6. Muka

- Oedema :............................................................................

7. Mata

- Conjungtiva :............................................................................

- Sclera :............................................................................

- Kotoran :............................................................................

8. Mulut

- Mukosa :............................................................................

9. Hidung

- Polip :............................................................................

10. Telinga

- Kebersihan :............................................................................:

- Gangguan pendengaran :............................................................................

11. Leher

- Pembesaran kelenjar tyroid :.................................................................

- Pembesaran pembuluh limfe :.................................................................

- Peningkatan vena jugularis :.................................................................

12. Dada

- Payudara :.................................................................

- Benjolan :.................................................................

- Areola :.................................................................

- Putting susu :.................................................................

- Nyeri tekan :.................................................................

- Pengeluaran cairan :.................................................................:

13. Abdomen

- Bekas luka operasi :.................................................................

- Pembesaran perut :.................................................................

- Bentuk perut :.................................................................

14. Pemeriksaan Genetalia :.................................................................

15. Pemeriksaan anus :.................................................................

16. Ekstremitas

- Oedema tangan dan jari :.........................................................

- Pucat telapak tangan dan ujung jari :.........................................................

- Oedema tibia dan kaki :.........................................................:

- Betis merah/keras :.........................................................

 - Varices tungkai :.........................................................

- Reflex patella kanan :.........................................................:

- Reflex patella kiri :.........................................................

17. Uji Diagnostic

- Dilakukan pemeriksaan gula darah :.........................................................

D. ASSESMENT

Hari/tanggal :..................................................................................................

Diagnosa :..................................................................................................:

Dasar :..................................................................................................

S :..................................................................................................

O :..................................................................................................

Masalah :..................................................................................................

Kebutuhan :..................................................................................................

Diagnosa :..................................................................................................

Tindakan segera :..................................................................................................

E. PLANNING
 Hari/Tanggal : Pukul :

1. ...........................................................................................................................

2. ...........................................................................................................................

3. ...........................................................................................................................

4. ...........................................................................................................................

Palopo,…………………….2021

MENGETAHUI

Preseptor Lahan Preseptor Institusi

(………………………..……..) (……………………………….)

PENDOKUEMNTASIAN ASUHAN KEBIDANAN REMAJA PUTRA

PADA An. “……..........” DENGAN…………………..….........................
 DI……......................................................................................................

A. IDENTITAS/BIODATA

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

Umur :.............................................................................................

Agama :.............................................................................................

Suku/Bangsa :.............................................................................................

Pendidikan :.............................................................................................

Pekerjaan :.............................................................................................

Alamat :.............................................................................................

No.HP/Telp :.............................................................................................

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

Umur :......................................... Umur :...............................

Agama :......................................... Agama :...............................

Suku/Bangsa :......................................... Suku/Bangsa :...............................

Pendidikan :......................................... Pendidikan :...............................

Pekerjaan :......................................... Pekerjaan :...............................

Alamat :......................................... Alamat :...............................

No.HP/Telp :......................................... No.HP/Telp :...............................

B. DATA SUBJEKTIF

Hari/tanggal : Pukul :

1. Alasan Kunjungan : .........................................................................

2. Keluhan-Keluhan :..........................................................................
3. Riwayat mimpi Basah :..........................................................................

a. Usia pertama :..........................................................................

b. Frekuensi :..........................................................................

c. Banyaknya :..........................................................................

d. Nyeri :..........................................................................

4. Keluhan yang dirasakan

a. Masalah didaerah kemaluan:..........................................................................

b. Nyeri payudara : .........................................................................

c. Lain-lain : .........................................................................

5. Pola pemenuhan kebutuhan Nutrisi, eliminasi dan aktifitas sehari-hari

a. Diet/Pola Nutrisi

Frekuensi :..........................................................................

Jenis makanan :..........................................................................

Jenis minuman :..........................................................................

Frekuensi :..........................................................................

b. Pola Eliminasi

- BAB

Frekuensi :..........................................................................

Warna :..........................................................................

Bau :..........................................................................

Konsistensi :..........................................................................

- BAK
 Frekuensi :..........................................................................

Warna :..........................................................................

Bau :..........................................................................

Konsistensi :..........................................................................

c. Aktivitas sehari-hari

- Istirahat Tidur

Siang :..........................................................................

Malam ...........................................................................

- Gangguan pola tidur : .........................................................................

- Pekerjaan :..........................................................................

- Personal Hygiene :..........................................................................

- Obat-obat yang pernah dikonsumsi: .........................................................

- Olahraga :..........................................................................

- Binatang Peliharaan :..........................................................................

6. Riwayat penyakit sistemik

Kelainan jantung :..........................................................................

Asma/TB paru :..........................................................................

Hepatiti :..........................................................................

DM :..........................................................................

Hipertensi :..........................................................................

Epilepsi :..........................................................................

Alergi ...........................................................................:
7. Riwayat penyakit keluarga

Kelainan jantung :..........................................................................

Kelainan Ginjal :..........................................................................

Asma/TB paru :..........................................................................

Hepatitis :..........................................................................

DM :..........................................................................

Hipertensi :..........................................................................

Epilepsi :..........................................................................

Alergi :..........................................................................

8. Riwayat sosial

Kegiatan diluar sekolah :..................................................

Kegiatan didalam sekolah :..................................................

Kegiatan dirumah :..................................................

Hubungan anggota keluarga dirumah :..................................................

Hubungan dengan teman sebaya :..................................................

Hubungan dengan lingkungan luar :..................................................

Aktifitas religi :..................................................

9. Masalah remaja

Pacaran :..................................................

Aktifitas seksualitas ( mastrubasi ) :..................................................

NAPZA dan alkohol :..................................................

Kebiasaan Merokok :..................................................

 Penggunaan alat kontrasepsi :..................................................

Akses pornografi ( filem, gambar ) :..................................................

10. Sumber informasi kespro seksual : .................................................

C. DATA OBJEKTIF

1. Pemeriksaan Umum

a. Keadaan umum :

b. Tingkat kesadaran :

c. Keadaan emosional :

d. Pemeriksaan tanda-tanda vital

TD : N :

P : S :

e. Antropometri

LILA :

BB :

TB :

2. Pemeriksaan head to toe

a. Kepala :

b. Wajah :

c. Telinga :

d. Hidung :

e. Mulut :

f. Leher :
 g. Dada

Payudara :

Benjolan :

Puting susu :

Areola :

Nyeri tekanan :

h. Abdomen

Bekas luka operasi :

Pembesaran perut :

Bentuk perut :

i. Pemeriksaan Genetalia :

j. Anus :

k. Ekstremitas

Pucat telapak tangan dan ujung jari :

Odema tangan dan kaki :

Betis merah, keras varices :

Refleks patela kiri dan kanan :

l. Pemeriksaan diagnostik :

D. ASSESMENT

Hari/ tanggal : Pukul :

Diagnosa :
 1. Masalah :

2. Kebutuhan :

E. PLANNING

Hari/ tanggal : Pukul :

1.

2.

3.

4.

5.

Hari/ tanggal : Pukul :

1.

2.

3.

4.

5.

Palopo , …………...2019

MENGETAHUI,

Preseptor Lahan Preseptor Institusi

(………………………..……..) (……………………………….)

PENDOKEMTASIAN ASUHAN KEBIDANAN PRA NIKAH

PADA “…..……………...” UMUR……………………..….TAHUN
 DENGAN………………………………………………………..……..
DI……………………………………………………………………..…….

A. IDENTITAS/BIODATA

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

Umur .........................................................................................

Suku / Bangsa :........................................................................................

Agama .........................................................................................

Pendidikan :........................................................................................

Pekerjaan .........................................................................................

Alamat .........................................................................................

B. DATA SUBJEKTIF

Hari/tanggal :........................ Pukul ...................................................

1. Kunjungan Ke :...............................................................................

2. Alasan kunjungan ini :...............................................................................

3. Keluhan-keluhan :...............................................................................

4. Pola pemenuhan kebutuhan nutrisi, eliminasi dan aktifitas sehari-hari

 Diet/pola nutrisi

........................................................................................................................

........................................................................................................................

 Pola Eliminasi
 BAB

........................................................................................................................

........................................................................................................................

BAK

........................................................................................................................

........................................................................................................................

 Aktivitas Sehari-hari

Istirahat tidur

........................................................................................................................

........................................................................................................................

Personal Hygiene

........................................................................................................................

........................................................................................................................

5. Riwayat penyakit sistemik

.............................................................................................................................

.............................................................................................................................

6. Riwayat penyakit keluarga

.............................................................................................................................

.............................................................................................................................

7. Riwayat Sosial
 .............................................................................................................................

.............................................................................................................................

8. Sumber informasi kesehatan reproduksi

.............................................................................................................................

.............................................................................................................................

C. DATA OBJEKTIF

1. Pemeriksaan Umum

2. Keadaan umum :

3. Tingkat kesadaran :

4. Keadaan emosional :

5. Pemeriksaan tanda-tanda vital

TD : N :

P : S :

6. Antropometri

LILA :

BB :

TB :

7. Pemeriksaan head to toe

Kepala :

Wajah :

Telinga :

Hidung :
 Mulut :

Leher :

Payudara :

Abdomen

Pemeriksaan Genetalia

Ekstremitas

8. Pemeriksaan diagnostik :

F. ASSESMENT

Hari/ tanggal : Pukul :

Diagnosa :

1. Masalah :

2. Kebutuhan :

G. PLANNING

Hari/ tanggal : Pukul :

1.

2.

3.

4.

5.

Hari/ tanggal : Pukul :

1.

2.
 3.

4.

5.

Palopo , …………...2019

MENGETAHUI,

Preseptor Lahan Preseptor Institusi

(………………………..……..) (……………………………….)