LAMPIRAN 3

ASKEB PENGKAJIAN

ASUHAN KEBIDANAN PADA IBU BERSALIN DENGAN KPD

DI RSUD KOTA KENDARI

TAHUN 2022

No. RM :

Tgl/jam Masuk :

Tgl/jam Pengkajian :

Nama Pengkaji :

A. Data Subjektif

1. Identitas Istri suami

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

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

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

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

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

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

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

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

2. Anamnesa

a. Keluhan utama

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

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

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

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

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

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

f. Riwayat kesehatan

a) Riwayat kesehatan yang lalu

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

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

Tanggal/

jam:.............................................................................................................................

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

VI. PELAKSANAAN

Tanggal/

jam:.............................................................................................................................

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

VII. EVALUASI
Tanggal/

jam:.............................................................................................................................

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

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

Assesment (A)

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

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

Planning (P)

Tanggal jam

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