ASUHAN KEBIDANAN KB DAN KESPRO

1. PENGKAJIAN
1.1 DATA SUBJEKTIF
Anamnesadilakukanoleh :...............................................Di....................................
Padatanggal.................................................. pukul.......................................................
1.1.1 IDENTITAS KLIEN No. Register :...........................
NamaKlien :...................................... NamaSuami :...........................
Umur :...................................... Umur :...........................
Suku/ Bangsa :...................................... Suku/ Bangsa :...........................
Agama :...................................... Agama :...........................
Pendidikan :...................................... Pendidikan :...........................
Pekerjaan :...................................... Pekerjaan :...........................
Penghasilan :...................................... Penghasilan :...........................
Alamat :...................................... Alamat :...........................

1.1.2 Alasankunjungansaatini
Kunjunganpertama Kunjunganulang

1.1.3 Keluhanutama
.....................................................................................................................................
.........................................................................................................................
1.1.4 Riwayatmenstruasi
 Menarche :.......................................................................................
 Siklusmenstruasi :......................(teratur/tidakteratur)
 Lama :.......................................................................................
 Banyaknyadarah :.......................................................................................
 Konsistensi :.......................................................................................
 Dysmenorhoe : Ya/tidak (sebelum/selama/sesudahmenstruasi)
 Flour albus : Ya/tidak (sebelum/selama/sesudahmenstruasi)
Warna:.......... Bau:........... Gatal:.............
1.1.5 Status perkawinan
 Kawin :........ Kali..............
 Lama kawin :.................................. tahun

1.1.6 Riwayatkehamilan, persalinan, dannifas yang lalu

Kehamilan Persalinan Nifas Anak
No Suamik K Ke
Umu penyu peno jeni tem penyu penyu L/ BB/ menyusu H/
. e B t
r l l s p l l P PB i M
 1.1.7 Riwayat KB
No. Jeniskontrase TempatPel AlasanPem WaktuPema EfekSamping Upaya yang dilakukan Ket
psi ayanan akaian kaian

1.1.8 Riwayatkesehatankeluarga
a. Keturunankembar :...........................................................................
Dari pihaksiapa :...........................................................................
b. Penyakitketurunan :...........................................................................
Jenispenyakit :...........................................................................
Dari pihaksiapa :...........................................................................
c. Penyakit lain dalamkeluarga :..............................................................
Jenispenyakit :..............................................................
Dari pihaksiapa :..............................................................

1.1.9 Riwayatkesehatan yang lalu

 Penyakitmenahun :...........................................................................
 Penyakitmenurun :...........................................................................
 Penyakitmenular :...........................................................................

1.1.10 KeadaanPsikososialdandukungankeluarga
- Alasanibumenjadiakseptor KB :................................................
- Motivasiibuuntukmenjadiakseptorberasaldari......................................
- Dukungandarisuami :................................................
- Dukungandarikeluarga yang lain :................................................

1.1.11 Polakebiasaansehari-hari
a. PolaNutrisi
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............................................................................................................................
Masalah yang dirasakan :...........................................................................
b. PolaEliminasi
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 ............................................................................................................................
Masalah yang dirasakan : ...........................................................................

c. Polaistirahattidur
.................................................................................................................
............................................................................................................................
Masalah yang dirasakan : ...........................................................................
d. PolaAktivitas
.................................................................................................................
............................................................................................................................
Masalah yang dirasakan : ...........................................................................
e. Polaseksualitas
.................................................................................................................
............................................................................................................................
Masalah yang dirasakan : ...........................................................................
f. PerilakuKesehatan
Penggunaanobat/jamu/rokok, dll...............................................................
............................................................................................................................

1.2 Data Objektif

1.2.1 PemeriksaanUmum
 Kesadaran :...................................................
 TekananDarah :...................................................
 Suhu :...................................................
 Nadi :...................................................
 RR :...................................................
 BB : ...................................................
 TB :...................................................

1.2.2 PemeriksaanKhusus
a. Inspeksi
 Kepala :..................................................
 Muka : Kelopakmata :..................................................
Conjungtiva :..................................................
Sklera :..................................................
 Mulutdangigi : Bibir :..................................................
Lidah :..................................................
Gigi :..................................................
 Hidung : Simetris :..................................................
Sekret :..................................................
Kebersihan :..................................................
 Leher : Pembesaran vena jugularis :..........................
Pembesarankelenjar thyroid :..........................
Pembesarankelenjargetahbening :..........................
 Dada : Simetris :..........................
Pembesaranpayudara :..........................
 Hiperpigmentasi :..........................
Papilamammae :..........................
Keluaran :..........................
Kebersihan :..........................
 Perut : Pembesaran :..........................
Bekaslukaoperasi :..........................
Linea :..........................
Striae :..........................
Pembesaran lien/ liver:..........................
 Anogenetalia : Vulva vagina warna :..........................
Luka parut :..........................
Oedema :..........................
Varises :..........................
Keluaran :..........................
Hemorroid :..........................
Kebersihan :..........................
 Ekstremitasatasdanbawah : Oedema :..........................
Varises :..........................
Kekakuansendi:......................
b. Palpasi
 Leher : Pembesaran vena jugularis :..........................
Pembesarankelenjar thyroid :..........................
Pembesarankelenjargetahbening :..............
Struma :..........................
 Dada : Benjolan/ Tumor :..........................
Keluaran :..........................
 Perut : Pembesaran lien/ liver :..........................
TFU :..........................
Kontraksi uterus :..........................
Kandungkemih :..........................
 Ekstremitasatasdanbawah : Oedema :........................

c. Auskultasi
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...........................................................................................................................
d. Perkusi
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1.2.3 Pemeriksaandalam (bilaadaindikasi)

......................................................................................................................
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1.2.4 PemeriksaanLaboratorium
Sekret : cairan vagina :..............................................................................................
IVA :........................................................................................................................
 PAP Smear:................................................................................................................
Darah : HB..............................................................................................................
WR.............................................................................................................
VDRL........................................................................................................
Urine : Albumin....................................................................................................
Reduksi.....................................................................................................

1.2.5 Pemeriksaanpenunjang yang lain

USG :.....................................................................................................
NST :....................................................................................................
RotgenFoto :....................................................................................................

2. ANALISA/DIAGNOSA:

3. RENCANA ASUHAN

4. PENATALAKSANAAN:

5. Evaluasi ( tgl....................................................jam...................................................................)

Subyektif Obyektif Assesment Planning