Nama .......................

POLTEKKES KEMENKES YOGYAKARTA Keterampilan ke.......

JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
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ASUHAN KEBIDANAN PADA AKSEPTOR KB………………
…………………………………………………………………………………………………………………
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NO. REGISTER : …………………………………….

MASUK RS TANGGAL, JAM :……………………………………..
DIRAWAT DI RUANG :……………………………………..

Biodata Ibu Suami

Nama : ....................................................... .......................................................
Umur : ....................................................... .......................................................
Pendidikan : ....................................................... .......................................................
Pekerjaan : ....................................................... .......................................................
Agama : ....................................................... .......................................................
Suku/ Bangsa : ....................................................... .......................................................
Alamat : ....................................................... .......................................................

DATA SUBJEKTIF
1. Kunjungan saat ini kunjungan pertama kunjungan ulang
Keluhan utama…………………………………………………………………………………………...
……………………………………………………………………………………………………….......
2. Riwayat Perkawinan
Kawin........ kali. Kawin pertama umur ......... tahun. Dengan suami sekarang.........................tahun
3. Riwayat menstruasi
Menarche umur...........tahun. Siklus...........hari. Teratur/tidak. Lama......................hari.
Sifat Darah : Encer/ Beku. Flour Albus: ya/tidak. Bau.................Dysmenorhoe : ya/tidak .
Banyak Darah ........................ HPM…………………………

4. Riwayat Kehamilan
P……………Ab…………..Ah…………….

H Persalin Nifa
an s
a Komplikasi
Umur Jenis BB
mi Tgl Penolon Ib Bayi JK Lahir Laktasi Komplikas
lahir kehamilan Persalin g u i
l
an
ke

5. Riwayat kontrasepsi yang digunakan

Jenis Mulai Berhenti/Ganti Cara

N Kontrase memakai
o psi Tanggal Oleh tempat Keluhan Tanggal Oleh Tempat Alasan

6. Riwayat kesehatan
a. Penyakit sistemik yang pernah/sedang diderita
.............................................................................................................................................................
.............................................................................................................................................................
b. Penyakit yang pernah/sedang diderita keluarga
.............................................................................................................................................................
.............................................................................................................................................................
 POLTEKKES KEMENKES YOGYAKARTA
JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================================================

c. Riwayat penyakit ginekologi

.............................................................................................................................................................
.............................................................................................................................................................
7. Pola pemenuhan kebutuhan sehari-hari
a. Pola Nutrisi Makan Minum
Frekuensi ..................................kali/hari ...................................kali/hari
Macam ................................................. .................................................
Jumlah ................................................. .................................................
Keluhan ................................................. .................................................
b. Pola Eliminasi BAB BAK
Frekuensi .................................. kali/hari ....................................kali/hari
Warna ................................................. .................................................
Bau ................................................. .................................................
Konsisten ................................................. .................................................
Jumlah ................................................. .................................................
c. Pola aktivitas
Kegiatan sehari-hari : ................................................................................................................
Istirahat/Tidur : malam.........................jam. siang............................jam
Seksualitas :Frekuensi.............................kali/minggu
Keluhan....................................................................................................
d. Personal Hygiene
Kebiasaan mandi.............kali/hari
Kebiasaan membersihkan alat kelamin ...........................................................................................
Kebiasaan mengganti pakaian dalam ..............................................................................................
Jenis pakaian dalam yang digunakan ..............................................................................................

8. Keadaan psikososal
a. Pengetahuan ibu tentang alat kontrasepsi
...................................................................................................................................................................
...................................................................................................................................................................
b. Pengetahuan ibu tentang alat kontrasepsi yang dipakai sekarang
...................................................................................................................................................................
...................................................................................................................................................................
c. Dukungan suami/ keluarga
...................................................................................................................................................................
...................................................................................................................................................................

DATA OBJEKTIF
1. Pemeriksaan Fisik
a. Keadaan umum................................................. Kesadaran...........................................................
b. Status emosional……………………………………………………………………………………..
c. Tanda Vital
Tekanan darah......................mmHg
Nadi......................................kali per menit
Pernafasan............................kali per menit
Suhu......................................○C
d. BB/ TB : ...........kg/....................cm
e. Kepala dan leher
Hiperpigmentasi : ..........................................................................................................
Mata : ..........................................................................................................
 POLTEKKES KEMENKES YOGYAKARTA
JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================================================
Mulut : ..........................................................................................................
Leher : ..........................................................................................................
f. Payudara
Bentuk : ..........................................................................................................
Putting susu : ..........................................................................................................
Massa/ tumor : ..........................................................................................................
g. Abdomen
Bentuk : ..........................................................................................................
Bekas luka : ..........................................................................................................
Massa/ tumor : ..........................................................................................................
h. Ekstremitas
Oedem : +/-
Varices :.............................................................................................................
Reflek Patela : kaki kanan………….kaki kiri ……………..
i. Genetalia luar
Tanda Chadwick :.............................................................................................................
Varices :.............................................................................................................
Bekas luka :.............................................................................................................
Pengeluaran :.............................................................................................................
j. Anus/ Hemoroid :............................................................................................................
2. Pemeriksaan dalam/ ginekologis
...................................................................................................................................................................
..................................................................................................................................................................
3. Pemeriksaan penunjang
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ANALISA
1. Diagnosa Kebidanan
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2. Masalah
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3. Kebutuhan
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4. Diagnosa Potensial
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5. Kebutuhan Tindakan Segera Berdasarkan Klien
a. Mandiri
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b. Kolaborasi
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c. Merujuk
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PENATALAKSANAAN, Tanggal …………………………….… Jam…............WIB

 POLTEKKES KEMENKES YOGYAKARTA
JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
===============================================================================================