LAMPIRAN 3

ASKEB PENGKAJIAN

ASUHAN KEBIDANAN PADA IBU BERSALIN

DENGAN KETUBAN PECAH DINI

DI RSUD KOTA KENDARI

TAHUN 2022

No. RM :

Tgl/jam Masuk :

Tgl/jam Pengkajian :

Nama Pengkaji :

I. IDENTIFIKASI DATA DASAR

A. Data Subj ektif

1. Identitas Istri suami

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

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

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

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

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

Suku/bangsa :......................... .....................................

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

Telp :......................... .....................................

2. Anamnesa

a. Keluhan utama

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 b. Riwayat keluhan utama :

a) Mulai timbul :......................................................................

b) Sifat keluhan :......................................................................

c) Lokasi keluhan :........................................................................

d) Pengaruh keluhan terhadap fungsi tubuh :................................

c. Riwayat obstetrik

a) Riwayat haid

Menarce

Siklus haid :.....................................................................

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

Perlangsungan :.....................................................................

Kelainan haid :.....................................................................

d. Riwayat kehamilan, persalinan dan nifas yang lalu

No Kehamilan Persalinan Nifas

Penolong Jenis Ku
Perlangsungan
Ke Tahun UK
persalinan persalinan ibu/bayi

e. Riwayat KB :..................................................................................

f. Riwayat kesehatan

a) Riwayat kesehatan yang lalu

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 b) Riwayat kesehatan sekarang

g. Riwayat kesehatan keluarga :

h. Pola kebutuhan Sehari-hari

a) Nutrisi

Pola makan sehari :...............................

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

Pantangan makanan :...............................

Pola minum :...............................

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

b) Eliminasi

a. BAK

Frekuensi....................jumlah...................warna..................

Keluhan.................................................................................

b. BAB

Frekuensi....................jumlah...................warna..................

Masalah.................................................................................

c) Istirahat

Siang..........................................malam......................................

Keluhan.......................................................................................

d) Personal Hygiene:.......................................................................

B. Data Objektif

1. Pemeriksaan Umum

KU :.............................................................................................

Kesadaran:.............................................................................................

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 TTV :TD:....................N:.....................S:................P:..................

2. Pemeriksaan fisik

Kepala :.............................................................................................

Wajah :.............................................................................................

Mata :.............................................................................................

Hidung :.............................................................................................

Mulut :.............................................................................................

Telinga :.............................................................................................

Leher

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

Abdomen : ..................................................................................

Genetalia luar : ..................................................................................

Anus : ..................................................................................

Ekstremitas :

1) Ekstremitas atas : ........................................................................

2) Ektemitas bawah : ........................................................................

II. INTERPESTASI DIAGNOSA/MASALAH AKTUAL

III. INTERPRETASI DIAGNOSA/MASALAH POTENSIAL

IV. EVALUASI PERLUNYA TINDAKAN SEGERA/KOLABORASI

V. PERENCANAAN

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Tanggal/jam:.............................................................................................................

VI. PELAKSANAAN

Tanggal/jam:.............................................................................................................

VII. EVALUASI

Tanggal/jam:.............................................................................................................

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 PENDOKUMENTASIAN ASUHAN KEBIDANAN
(SOAP)

Biodata

1. Identitas Istri suami

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

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

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

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

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

Suku/bangsa :......................... .....................................

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

Telp : ........................ .....................................

Data Subyektif (S)

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

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

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

Data Obyektif (O)

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

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

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

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

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