Lampiran Panduan Stase 1, 2 & 3 Tahun 2021

Prodi Pendidikan Profesi Bidan Poltekkes Kemenkes Palangka Raya

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Lampiran Panduan Stase 1, 2 & 3 Tahun 2021
Prodi Pendidikan Profesi Bidan Poltekkes Kemenkes Palangka Raya

Lampiran 33. Format Pengkajian Kehamilan

FORMULIR PENGKAJIAN PADA IBU HAMIL

Hari / Tanggal : Pukul

Tempat Pengkajian :
Nomor Rekam Medik :

A. DATA SUBJEKTIF

A. IDENTITAS/BIODATA

Nama Ibu : Nama Suami :

Umur : Umur :
Suku/Bangsa : Suku/Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat Rumah : Alamat rumah :
Telepon : Telepon :

B. ANAMNESA (DATA SUBJEKTIF)

Tanggal : Pukul :

1. Kunjungan ke : ............................................................................
2. Alasan kunjungan/ keluhan utama
..............................................................................................................................

..............................................................................................................................
..............................................................................................................................
3. Riwayat psikososial
a. Kehamilan ini ( ) Direncanakan
( ) Tidak direncanakan
( ) Diterima

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Lampiran Panduan Stase 1, 2 & 3 Tahun 2021
Prodi Pendidikan Profesi Bidan Poltekkes Kemenkes Palangka Raya
( ) Tidak diterima

b. Perasaan tentang kehamilan ini : ..........................................................

c. Emosional ibu pada saat pengkajian : ..........................................................
d. Jenis kelamin yang diharapkan : ..........................................................

e. Status perkawinan Kawin I

Umur : ................Tahun Umur suami : ......Tahun

Lamanya : ............... Anak .....orang Abortus Kawin II : ......kali

Umur : ................Tahun Umur suami : ......Tahun

Lamanya : ............... Anak .....orang Abortus : ......kali

f. Susunan keluarga/ genogram :

g. Perilaku kesehatan
Merokok :
Alkohol :
Narkoba :

4. Riwayat obsetri
a. Riwayat haid
Umur menarche : ..........Tahun Teratur/ tidak teratur
Siklus : ..........Hari Lamanya..........................hari
Banyaknya : .......... kali / pembalut, Sifat darah :..............
Warna darah :.........................

b. Riwayat kehamilan

HPHT :.........................................TP
:...................................

Keluhan-keluhan Trimester I : ..........................................................

Trimester II : .........................................................

Trimester III: .........................................................

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Lampiran Panduan Stase 1, 2 & 3 Tahun 2021
Prodi Pendidikan Profesi Bidan Poltekkes Kemenkes Palangka Raya
Pergerakan anak pertama kali dirasakan : Hamil......................................Minggu

Bila pergerakan anak sudah terasa, pergerakan anak dalam 24 jam...........................kali

Bila lebih dari 20 kali dalam 24 jam, dengan frekuensi.........................................................detik

Bila ada pergerakan keluhan yang dirasakan : .............................................

6. Riwayat kehamilan, persalinan dan nifas yang lalu G P A :

Hamil Tgl/Bln/Thn BBL JK Jenis Umur Penyulit Penolong Ket.
Ke persalinan kehamilan kehamilann

7. Riwayat KB
…………………………………………………………………………………

…………………………………………………………………………………
……………………………………………………………………………........

8. Riwayat kesehatan
Penyakit yang pernah diderita

Penyakit Klien Keluarga

Jantung
Tekanan darah tinggi
Hepar
Diabetes melitus
PHS

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Lampiran Panduan Stase 1, 2 & 3 Tahun 2021
Prodi Pendidikan Profesi Bidan Poltekkes Kemenkes Palangka Raya

Campak
Malaria
TBC
Keturunan kembar : ................................. Dari pihak : ....................

9. Riwayat Kebiasaan
a. Pola makan
........................................................................................................................

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

b. Pola eliminasi
........................................................................................................................
........................................................................................................................
........................................................................................................................

c. Personal hygiene
........................................................................................................................
........................................................................................................................
........................................................................................................................

d. Aktivitas sehari-hari
........................................................................................................................

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

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

e. Pola istirahat dan tidur

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

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

........................................................................................................................ f. Seksualitas

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

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

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

10. Riwayat imunisasi

TT: Jumlah.........kali

Tanggal Pemberian TT :

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Lampiran Panduan Stase 1, 2 & 3 Tahun 2021
Prodi Pendidikan Profesi Bidan Poltekkes Kemenkes Palangka Raya
I............ II............. III............. IV............. V.............

11. Riwayat Vaksin C19

Jumlah.........kali

Tanggal Pemberian :

I............ II.............

II. DATA OBJEKTIF

C. PEMERIKSAAN FISIK 1.
Kesadaran umum
..............................................................................................................................
..............................................................................................................................

2. Tanda-tanda Vital

Respirasi :.................x/menit Nadi.................x/menit

Tekanan darah :.................mmHg Suhu.................°C

3. BB sekarang : ...........kg
BB sebelum hamil : ...........kg
TB : ...........cm
LILA : ...........cm
4. Kepala dan rambut
Warna rambut : ........................................................................................
Distribusi : ........................................................................................
Kebersihan : ........................................................................................
Kekuatan : ........................................................................................

Keadaan kulit kepala : ........................................................................................

5. Muka
Oedema :........................................................................................Cloasmagravidarum :
........................................................................................

6. Mata

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Lampiran Panduan Stase 1, 2 & 3 Tahun 2021
Prodi Pendidikan Profesi Bidan Poltekkes Kemenkes Palangka Raya
Conjungtiva : ........................................................................................

Sklera : .......................................................................................

Kemampuan penglihatan : ...................................................................................

7. Hidung
Pengeluaran...........................................................................................Kemampuan
penciuman: .....................................................................................

8. Mulut
Gigi : ........................................................................................
Gusi : ........................................................................................
Keadaan mukosa bibir: ........................................................................................
9. Telinga
Letak telinga : ........................................................................................

Kemampuan pendengaran: ..................................................................................

Pengeluaran : .......................................................................................
10. Leher
Pembesaran kelenjar tiroid : ................................................................ Pembesaran vena
jugularis : ................................................................ Pembesaran kelenjar getah bening :
................................................................
11. Dada
Simestris : ........................................................................................

Pergerakan dada : ........................................................................................

12. Mamae
Kesimetrisan............................................................................................Hiperpigmentasi
areola: ......................................................................................

Bentuk payudara....................................................................................................Keadaan
putting susu : ........................................................................................ Cairan yang keluar :
........................................................................................

13. Abdomen
Warna/ Hiperpigmentasi : ...................................................................................

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

Linea : ........................................................................................
Striae : ........................................................................................
Leopold I : ................................................................TFU..........Cm
Leopold II : ........................................................................................
Leopold III : ........................................................................................
Leopold IV : ........................................................................................
Perlimaan : ........................................................................................
DJJ : .......................................................................................

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Lampiran Panduan Stase 1, 2 & 3 Tahun 2021
Prodi Pendidikan Profesi Bidan Poltekkes Kemenkes Palangka Raya
TBBJ : ........................................................................................

14. Genitalia
Oedema : ........................................................................................
Varises : ........................................................................................
Pembesaran kelenjar : ........................................................................................

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

Bekas episiotomi : ........................................................................................

Kemerahan : ........................................................................................
Nyeri : ........................................................................................
Chadwick : ........................................................................................
15. Anus : ........................................................................................
16. Ekstremitas
Tangan : kuku : ........................................................................................
Oedema :........................................................................................
Kaki : varises : ........................................................................................
Oedema : ........................................................................................
Refleks patella : ..................................................................................

17. Punggung
Lordosis : ........................................................................................
Kiposis : ........................................................................................
Skoliosis : ........................................................................................
Ketuk costovetebra : ........................................................................................

18. Ukuran panggul luar

Distantia spinarum : ........................................................................................ Distantia
kristarum :........................................................................................Conjungata eksterna :
........................................................................................
Lingkar panggul : ........................................................................................
19. Ukuran panggul dalam: .......................................................................................
D. PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium
Tanggal : ............................................

Darah :

HB : ................................... Golongan darah

: ...................................

Rhesus : ...................................

Urine : Protein : ...................................

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Lampiran Panduan Stase 1, 2 & 3 Tahun 2021
Prodi Pendidikan Profesi Bidan Poltekkes Kemenkes Palangka Raya
Reduksi : ...................................
RDT Malaria : ............................................
Sifilis : ............................................
HIV AIDS : ............................................
HBs Ag : ............................................

2. Pemeriksaan penunjang lainnya

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

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

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

……………………………,....................

Pembimbing lahan praktik Mahasiswa

(...........................................) (…………………………….)
NIP.......................................... NIM…………………………….

Mengetahui
Pembimbing
Institusi

(.......................................)
NIP...........................................

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