ASUHAN KEBIDANAN KEHAMILAN PADA NY.

“ ”
DI RS BHAYANGKARA PALEMBANG
TAHUN 2022

No. RM :

Tanggal pengkajian :

Jam pengkajian :

BIODATA

Nama Ibu : Ny. Nama Suami : Tn.

Umur : tahun Umur : tahun
Suku Bangsa : Suku Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat :

Telp : Telp :

A. DATA SUBYEKTIF

1. Alasan Datang

…………………………………………………………………………………….
…………………………………………………………………………………….
…………………………………………………………………………………….
2. Data Kebidanan

a. Riwayat Menstruasi

Umur menarche : tahun Siklus : hari

lamanya haid : hari Teratur/Tidak :

 jumlah darah haid : × ganti pembalut Dismenorea :

b. Riwayat Perkawinan

Kawin : Ya / Tidak Usia menikah : tahun

Status perkawinan : Lamanya : tahun

c. Riwayat Kehamilan, Persalinan dan Nifas yang Lalu

NO Tahun Tempat Usia Jenis Penolong Penyulit Anak Keadaan

Lahir Bersalin Kehamilan Persalianan Persalianan JK/BB/PB Anak
Sekarang

d. Riwayat Hamil Sekarang

GPA :G P A

HPHT :

TP :

Usia Kehamilan :

ANC :

TM 1 :

TM II :

TM III :

Tablet Fe :

Imunisasi TT : Status imunisasi TT

TT1 :

TT2 :
 TT3 :

TT4 :

TT5 :

Keluhan :

TM I :

TM II :

TM III :

e. Riwayat Keluarga Berencana

Pernah menjadi akseptor KB : Ya / Tidak

Metode KB yang pernah dipakai :

Lama : tahun

Alasan berhenti :

Masalah / keluhan :

3. Data Kesehatan

a. Riwayat penyakit yang pernah diderita pasien

Penyakit menular (AIDS/Sifilis/TBC, dsb) :
Penyakit keturunan (Hipertensi/jantung/ginjal/DM) :
b. Riwayat penyakit yang pernah dideita keluarga pasien
Penyakit menular (AIDS/Sifilis/TBC, dsb) :
Penyakit keturunan (Hipertensi/jantung/ginjal/DM) :
c. Riwayat operasi yang pernah dijalani :
d. Riwayat kehamilan dan persalinan kembar :
4. Data Kebasaan Sehari-Hari

a. Nutrisi

1) Pola Makan : kali/sehari

Pagi : …………………………………………………………………...

Siang : …………………………………………………………………...
 Sore : …………………………………………………………………...

2) Pola Minum :

Air putih : gelas/hari ( cc)

Susu :

Teh/Kopi :

b. Pola Eliminasi

1) BAK : kali/hari; warna : keluhan :

2) BAB : kali/hari; karakteristik : keluhan :

c. Pola Istirahat dan Tidur

1) Malam : jam/hari 3) Aktivitas :

2) Siang : jam/hari

d. Personal Hygiene

1) Mandi : kali/hari

2) Gosok gigi : kali/hari

3) Ganti pakaian dalam : kali/hari

5. Data Psikososial

a. Hubungan dengan suami dan keluarga : ……………………………………………

b. Harapan terhadap kehamilan : ……………………………………………

c. Rencana melahirkan : ……………………………………………

d. Rencana menyusui : ……………………………………………

e. Rencana merawat bayi : ……………………………………………

f. Persiapan yang dilakukan : ……………………………………………

……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
B. DATA OBYEKTIF

a. Pemeriksaan Fisik

1) Keadaan Umum : …………….

2) Kesadaran : …………….

3) Tinggi Badan : cm

4) Tanda – tanda Vital

Tekanan Darah : mmHg Pernapasan : x per menit

Nadi : × per menit Suhu : °C

5) LILA : cm

6) Berat Badan

Sebelum hamil : kg

Sekarang : kg Pertambahan BB : kg

7) IMT :

b. Pemeriksaan Kebidanan

1) Inspeksi

Rambut : ………………………………………………………………..

Muka : ………………………………………………………………..

Mata : ………………………………………………………………..

Hidung : ………………………………………………………………..

Mulut : ………………………………………………………………..

Gigi / Gusi : ………………………………………………………………..

Leher : ………………………………………………………………..

Payudara : ………………………………………………………………..

Abdomen : ………………………………………………………………..
 Genetalia : ………………………………………………………………..

Ekstremitas Atas : ………………………………………………………………..

Ekstremitas Bawah : ………………………………………………………………..

2) Palpasi

Leopold I : ……………………………………………………………………..
…………………………………………………………………………………………
…………………………………………………………………………………………

Leopold II : ……………………………………………………………………..
…………………………………………………………………………………………
Leopold III : ……………………………………………………………………..
…………………………………………………………………………………………
Leopold IV : ……………………………………………………………………..

3) Auskultasi

DJJ : kali/menit

Lokasi :

4) Perkusi

Refleks patella : kanan ( ) / kiri ( )

c. Pemeriksaan Penunjang

1) Darah

Golongan darah : HIV : Sifilis :

Hemoglobin : HbSAg :

2) Urin

Protein Urine :

Glukosa Urine :

C. ANALISA

Diagnosa : ……………………………………………………………………………..
………………………………………………………………………………
………………………………………………………………………………
D. PENATALAKSANAAN

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Palembang, Oktober 2022

Pembimbing Lahan Praktik Mahasiswa

Tri Wulandari
NIM PO.71.24.2.22.072

Mengetahui.
Pembimbing Institusi

Murdiningsih, SST, SPd, M.Kes

NIP 19571229 197811 2 001
 ASUHAN KEBIDANAN IBU BERSALIN PADA NY. “ ”

DI RS BHAYANGKARA PALEMBANG

TAHUN 2022

No. RM :

Tanggal pengkajian :

Jam pengkajian :

BIODATA

Nama Ibu : Ny. Nama Suami : Tn.

Umur : tahun Umur : tahun
Suku Bangsa : Suku Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat :

Telp : Telp :

A. DATA SUBJEKTIF
1. Alasan Datang
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
2. Data Kebidanan

a. Riwayat Menstruasi

Umur menarche : tahun Siklus : hari

lamanya haid : hari Teratur/Tidak :

 jumlah darah haid : × ganti pembalut Dismenorea :

b. Riwayat Perkawinan

Kawin : Ya / Tidak Usia menikah : tahun

Status perkawinan : Lamanya : tahun

c. Riwayat Kehamilan, Persalinan dan Nifas yang Lalu

NO Tahun Tempat Usia Jenis Penolong Penyulit Anak Keadaan

Lahir Bersalin Kehamilan Persalianan Persalianan JK/BB/PB Anak
Sekarang

d. Riwayat Hamil Sekarang

GPA :G P A

HPHT :

TP :

Usia Kehamilan :

Gerakan janin :

ANC :

TM 1 :

TM II :

TM III :

Keluhan :

TM I : TM III :

TM II :
3. Data Kesehatan

a. Riwayat penyakit yang pernah diderita pasien

Penyakit menular (AIDS/Sifilis/TBC, dsb) :
Penyakit keturunan (Hipertensi/jantung/ginjal/DM) :
b. Riwayat penyakit yang pernah dideita keluarga pasien
Penyakit menular (AIDS/Sifilis/TBC, dsb) :
Penyakit keturunan (Hipertensi/jantung/ginjal/DM) :
c. Riwayat operasi yang pernah dijalani :
d. Riwayat kehamilan dan persalinan kembar :
4. Data Kebasaan Sehari-Hari

a. Nutrisi

1) Terakhir makan : pukul WIB

Menu makan : ………………………………………………………………..

2) Terakhir minum : pukul WIB

Jenis : ………………………………………………………………..

b. Pola Eliminasi

1) Terakhir BAK : Pukul WIB; warna :

keluhan :

2) Terakhir BAB : Pukul WIB; karakteristik :

keluhan :

c. Pola Istirahat Terakhir

Terakhir tidur : Pukul WIB

d. Personal Hygiene

1) Mandi terakhir : pukul WIB

2) Gosok gigi terakhir : pukul WIB

3) Ganti pakaian dalam terakhir : pukul WIB

5. Data Psikososial

a. Pengambilan keputusan dalam keluarga :

b.Rencana menyusui :

c. Rencana merawat bayi :

d. Hubungan dengan suami dan keluarga :

e. Kepercayaan yang berhubungan dengan kehamilan, persalinan, nifas :

B. DATA OBJEKTIF

1. Pemeriksaan Umum

a. Keadaan Umum : ……………..

b. Kesadaran : ……………..

c. Tinggi Badan : cm

d. Berat Badan : kg

e. Tanda – tanda Vital

Tekanan Darah : mmHg Pernapasan : × per menit

Nadi : × per menitSuhu : °C

2. Pemeriksaan Kebidanan

a. Inspeksi

1) Kapala : ………………………………………………………………...

2) Muka : ………………………………………………………………...

3) Mata : ………………………………………………………………...

4)Hidung : ………………………………………………………………...

5) Mulut : ………………………………………………………………...

6) Gigi / Gusi : ………………………………………………………………...

7) Leher : ………………………………………………………………...

8) Payudara : ………………………………………………………………...
 9) Abdomen : ………………………………………………………………...

10) Genetalia : ………………………………………………………………...

11) Ekstremitas Atas : ………………………………………………………………...

12) Ekstremitas Bawah : ………………………………………………………………...

b. Palpasi

TFU : …………………………………………………………………………………..
…………………………………………………………………………………..
…………………………………………………………………………………..
TBJ : ( - ) x 155 = gram

His :

c. Auskultasi

DJJ : x/menit Punctum maximum :

Sifat :

d. Perkusi

Reflek Patella : Kanan ( ) / Kiri ( )

e. Pemeriksaan Dalam

Portio :

Pendataran : %

Pembukaan : cm

Ketuban :

Presentasi :

Penurunan : Hodge

Penunjuk :
d. Pemeriksaan Penunjang

1) Darah

Golongan darah : HIV : HbSAg :

Hemoglobin : Sifilis :

2) Urin

Protein Urine :

Glukosa Urine :

C. ANALISA

Diagnosa : ......................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

D. PENATALAKSANAAN

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 CATATAN PERKEMBANGAN

Hari / Tanggal :

Jam : WIB

S : ……………………………………………………………………………………….
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O :

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A : ...................................................................................................................................
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Palembang, Oktober 2022

Pembimbing Lahan Praktik Mahasiswa

Tri Wulandari
NIM PO.71.24.2.22.072

Mengetahui.
Pembimbing Institusi

Murdiningsih, SST, SPd, M.Kes

NIP 19571229 197811 2 001
 ASUHAN KEBIDANAN PADA BAYI BARU LAHIR NY.” ”

DI RS BHAYANGKARA PALEMBANG

TAHUN 2022

No. RM :

Tanggal Pengkajian :

Jam Pengkajian :

IDENTITAS BAYI

Nama : By. Ny.

Tanggal/Jam Lahir :

Jenis Kelamin :

IDENTITAS ORANGTUA

Nama Ibu : Ny. Nama Suami : Tn.

Umur : tahun Umur : tahun
Suku Bangsa : Suku Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat :

Telp : Telp :

A. DATA SUBJEKTIF
1. Keluhan Utama
.....................................................................................................................................
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 2. Data Kebidanan
a. Riwayat Kehamilan
Anak ke :
Umur Kehamilan :
Imunisasi TT :
Kelainan Kehamilan :
b. Riwayat Persalinan
Jenis Persalinan :
Penolong Persalinan :
Lama Persalinan
Kala I :
Kala II :
Kala III :
Kala IV :
B. DATA OBJEKTIF
1. Pemeriksaan Fisik
Keadaan umum : ……………
Kesadaran : ……………
2. Pemeriksaan Kebidanan
a. Inspeksi
Kepala : ……………………………………………………………………
Mata : ……………………………………………………………………
Hidung : ……………………………………………………………………
Telinga : ……………………………………………………………………
Mulut : ……………………………………………………………………
Leher : ……………………………………………………………………
Dada : ……………………………………………………………………
Abdomen : ……………………………………………………………………
Tali Pusat : ……………………………………………………………………
Genitalia : ……………………………………………………………………
Anus : ……………………………………………………………………
 Ekstremitas : ……………………………………………………………………
Punggung : ……………………………………………………………………
Kulit : ……………………………………………………………………
3. Pemeriksaan Antopometri
BB : gram LD : cm
PB : cm LILA : cm
LK : cm
4. Nutrisi
ASI :
Masalah :
5. Pemeriksaan Refleks
Refleks Moro : Refleks Soching :
Refleks Rooting : Refleks Tonick neck :
Refleks Graps :
6. Pemeriksaan Penunjang :

7. Kolom Telapak Kaki

KIRI KANAN
C. ANALISA DATA
Diagnosa : ………………………………………………………………………….

D. PENATALAKSANAAN
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Palembang, Oktober 2022

Pembimbing Lahan Praktik Mahasiswa

Tri Wulandari
NIM PO.71.24.2.22.072

Mengetahui.
Pembimbing Institusi

Murdiningsih, SST, SPd, M.Kes

NIP 19571229 197811 2 001
 ASUHAN KEBIDANAN PADA IBU NIFAS NY. “ ”

DI RS BHAYANGKARA PALEMBANG

TAHUN 2022

No. RM :

Tanggal Pengkajian :

Jam Pengkajian :

BIODATA

Nama Ibu : Ny. Nama Suami : Tn.

Umur : tahun Umur : tahun
Suku Bangsa : Suku Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat :

Telp : Telp :

A. DATA SUBJEKTIF

1. Alasan Datang

………………………………………………………………....................................
………………………………………………………………....................................
………………………………………………………………....................................
2. Data Kebidanan

a. Riwayat Menstruasi

Umur menarche : tahun Siklus : hari

lamanya haid : hari Teratur/Tidak :

 jumlah darah haid : × ganti pembalut Dismenorea :

b. Riwayat Perkawinan

Kawin : Ya / Tidak Usia menikah : tahun

Status perkawinan : Lamanya : tahun

c. Riwayat Kehamilan, Persalinan dan Nifas yang Lalu

NO Tahun Tempat Usia Jenis Penolong Penyulit Anak Keadaan

Lahir Bersalin Kehamilan Persalianan Persalianan JK/BB/PB Anak
Sekarang

d. Riwayat Persalinan Sekarang

1) Tanggal persalinan :

2) Jam : WIB

3) Jenis persalinan :

4) Tempat bersalin :

5) Penolong :

6) Kala I :

7) Kala II :

8) Kala III :

9) Keluhan :

10) Ketuban :

11) Plasenta :

13) Komplikasi :
e. Riwayat Keluarga Berencana

1) Pernah menjadi akseptor KB : Ya / Tidak

2) Metode KB yang pernah dipakai :

3) Lama : tahun

4) Alasan berhenti :

5) Masalah / keluhan :

f. Data Psikososial

1) Hubungan ibu, suami, dan keluarga :

2) Tanggapan ibu, suami, dan keluarga terhadap kelahiran bayi :

3) Pengambilan keputusan dalam keluarga :

4) Kebiasaan yang dilakukan dan mempengaruhi nifas :

g. Data Kesehatan

1) Riwayat penyakit yang pernah diderita pasien

Penyakit menular (AIDS/Sifilis/TBC, dsb) :
Penyakit keturunan (Hipertensi/jantung/ginjal/DM) :
2) Riwayat penyakit yang pernah dideita keluarga pasien
Penyakit menular (AIDS/Sifilis/TBC, dsb) :
Penyakit keturunan (Hipertensi/jantung/ginjal/DM) :
3) Riwayat operasi yang pernah dijalani :
4) Riwayat kehamilan dan persalinan kembar :

h. Data Kebasaan Sehari-Hari

1. Nutrisi

a) Pola Makan : kali/sehari

Pagi : …………………………………………………………………….

Siang : …………………………………………………………………….

Sore : …………………………………………………………………….
 b) Pola Minum :

Air putih : gelas/hari ( cc)

Susu :

Teh/Kopi :

2. Pola Eliminasi

a) BAK : kali/hari; warna : keluhan :

b) BAB : kali/hari; karakteristik :

keluhan :

3. Pola Istirahat dan Tidur

a) Malam : jam/hari c) Aktivitas :

b) Siang : jam/hari

4. Rencana Menyusui :

5. Personal Hygiene

a) Mandi : kali/hari c) Ganti pakaian dalam : kali/hari

b) Gosok gigi : kali/hari d) Pembalut : kali/hari

B. DATA OBYEKTIF

1. Pemeriksaan Fisik

a) Keadaan Umum : ……………………………….

b) Kesadaran : ……………………………….

c) Tinggi Badan : cm

d) Berat Badan : kg

e) Tanda – tanda Vital

Tekanan Darah : mmHg Pernapasan : x per menit

Nadi : × per menit Suhu : °C

b. Pemeriksaan Kebidanan

1) Inspeksi

Rambut : ………………………………………………………………...

Muka : ………………………………………………………………...

Mata : ………………………………………………………………...

Hidung : ………………………………………………………………...

Mulut : ………………………………………………………………...

Gigi / Gusi : ………………………………………………………………...

Leher : ………………………………………………………………...

Payudara : ………………………………………………………………...

Abdomen : ………………………………………………………………...

Genetalia : ………………………………………………………………...

Ekstremitas Atas : ………………………………………………………………...

Ekstremitas Bawah : ………………………………………………………………...

2) Palpasi

TFU : ………………………………………………………………...

Payudara : ………………………………………………………………...

Kandung Kemih : ………………………………………………………………...

c. Pemeriksaan Penunjang

1) Darah

Golongan darah : HIV : Sifilis :

Hemoglobin : HbSAg :

2) Urin

Protein Urine :

Glukosa Urine :
D. ANALISA

Diagnosa : ……………………………………………………………………………..

D. PENATALAKSANAAN

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Palembang, Oktober 2022

Pembimbing Lahan Praktik Mahasiswa

Tri Wulandari
NIM PO.71.24.2.22.072

Mengetahui.
Pembimbing Institusi

Murdiningsih, SST, SPd, M.Kes

NIP 19571229 197811 2 001
 ASUHAN KEBIDANAN NEONATUS, BAYI, DAN BALITA
DI RS BHAYANGKARA PALEMBANG
TAHUN 2022

No. RM :

Tanggal Pengkajian :

Jam Pengkajian :

IDENTITAS BAYI
Nama :
Umur :
Tanggal lahir :
Jenis Kelamin :

IDENTITAS ORANG TUA

Nama Ibu : Ny. Nama Suami : Tn.
Umur : tahun Umur : tahun
Agama : Agama :
Suku/Bangsa : Suku/Bangsa :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat :

A. DATA SUBJEKTIF
1. Alasan Datang
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2. Riwayat Kesehatan
Kesehatan Anak :
Kesehatan Keluarga :
 3. Riwayat Imunisasi
No. Jenis I II III IV Keterangan
1
2
3
4
5
4. Pola Nutrisi
Jenis Asi/PASI :
Frekuensi :
5. Pola Eliminasi
a. BAK
Frekuensi : kali/hari Keluhan :
Warna :
b. BAB
Frekuensi : kali/hari Konsistensi :
Warna : Keluhan :

B. DATA OBJEKTIF
1. Pemeriksaan umum
Keadaan umum : ………………………………………………………………..
Kesadaran : ………………………………………………………………..
Tanda-Tanda Vital
Pernapasan : kali/menit
Nadi : kali/menit
Suhu : °C
2. Pemeriksaan Antropometri
Berat Badan : Lingkar Dada : cm
Panjang Badan : cm LILA : cm
Lingkar Kepala : cm
 3. Pemeriksaan Khusus
Kepala : …………………………………………………………………………….
Muka : …………………………………………………………………………….
Mata` : …………………………………………………………………………….
Telinga: …………………………………………………………………………….
Hidung: …………………………………………………………………………….
Mulut : …………………………………………………………………………….
Leher : …………………………………………………………………………….
Dada : …………………………………………………………………………….
Perut : …………………………………………………………………………….
Tungkai: …………………………………………………………………………….
Genetalia : ………………………………………………………………………….
4. Pemeriksaan Penunjang

C. ANALISA DATA
Diagnosa : ………………………………………………………………………

D. PENATALAKSANAAN
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Palembang, Oktober 2022

Pembimbing Lahan Praktik Mahasiswa

Tri Wulandari
NIM PO.71.24.2.22.072

Mengetahui.
Pembimbing Institusi

Murdiningsih, SST, SPd, M.Kes

NIP 19571229 197811 2 001
 ASUHAN KEBIDANAN PADA AKSEPTOR KB NY “ ”
DI RS PALEMBANG
TAHUN 2022

No. RM :

Tanggal Pengkajian :

Jam Pengkajian :

BIODATA
Nama Ibu : Ny. Nama Suami : Tn.
Umur : tahun Umur : tahun
Agama : Agama :
Suku/Bangsa : Suku/Bangsa :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat :

A. DATA SUBJEKTIF
1. Alasan Datang
……………………………………………………………………………………….
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2. Status Perkawinan
Umur kawin : tahun
Lama kawin :
3. Riwayat Menstruasi
Menarche : tahun
Siklus : hari Teratur/Tidak :
Lamanya : hari Warna :
Jumlah : x ganti pembalut Dismenorea :
4. Riwayat kehamilan, persalinan dan nifas yang lalu
NO Tahun Tempat Usia Jenis Penolong Penyulit Anak Keadaan
Lahir Bersalin Kehamilan Persalianan Persalianan JK/BB/PB Anak
Sekarang

5. Riwayat kontrasepsi yang digunakan

Pernah menjadi akseptor KB : Ya / Tidak

Metode KB yang pernah dipakai :

Lama : tahun

Alasan berhenti :

Masalah / keluhan :

6. Riwayat Kesehatan
a. Riwayat penyakit yang pernah diderita pasien
Penyakit menular (AIDS/Sifilis/TBC, dsb) :
Penyakit keturunan (Hipertensi/jantung/ginjal/DM) :
b. Riwayat penyakit yang pernah dideita keluarga pasien
Penyakit menular (AIDS/Sifilis/TBC, dsb) :
Penyakit keturunan (Hipertensi/jantung/ginjal/DM) :
c. Riwayat operasi yang pernah dijalani :
7. Data kebutuhan dasar
a. Nutrisi
1) Pola Makan
Frekuensi : x/hari
Jenis :
Pantangan :
2) Pola minum
Air putih : gelas/hari ( cc) Susu :
Kopi/Teh :
 b. Pola Eliminasi
1) BAK
Frekuensi : x/hari Keluhan :
Warna :
2) BAB
Frekuensi : x/hari Warna :
Konsistensi : Keluhan :
3) Pola Aktivitas dan Istirahat
Tidur Malam : jam/hari
Tidur Siang : jam/hari
Aktivitas :
4) Pola Kebersihan Diri
Mandi : x/hari
Sikat gigi : x/hari
Ganti Pakaian Dalam : x/hari
Pola Seksualitas :

B. DATA OBJEKTIF
1. Pemeriksaan Umum
Keadaan umum :
Kesadaran :
Tanda-tanda Vital
a. TD : mmHg
b. Nadi : x/menit
c. Pernafasan : x/menit
d. Suhu : °C
TB : cm
BB : kg
2. Pemeriksaan Fisik
Kepala : …………………………………………………………………….
Muka : …………………………………………………………………….
Mata : …………………………………………………………………….
Hidung : …………………………………………………………………….
Mulut : …………………………………………………………………….
Telinga : …………………………………………………………………….
Leher : …………………………………………………………………….
Payudara : …………………………………………………………………….
Abdomen : …………………………………………………………………….
Genitalia : …………………………………………………………………….
 Ekstremitas Atas : …………………………………………………………….
Ekstremitas bawah : …………………………………………………………….
3. Pemeriksaan ginekologi
Pemeriksaan dalam : .…………………………………………………………….
Inspekulo : ………………………………………………………………

4. Pemeriksaan laboratorium
1. Darah 2. Urine
Golongan Darah : Glukosa :
Hb : Protein :
C. ANALISA DATA
Diagnosa : ………………………………………………………………………..

D. PENATALAKSANAAN
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Palembang, Oktober 2022

Pembimbing Lahan Praktik Mahasiswa

Tri Wulandari
NIM PO.71.24.2.22.072

Mengetahui.
Pembimbing Institusi

Murdiningsih, SST, SPd, M.Kes

NIP 19571229 197811 2 001
 ASUHAN KEBIDANAN KESEHATAN REPRODUKSI PADA
DI RS PALEMBANG
TAHUN 2022

No. RM :

Tanggal Pengkajian :

Jam Pengkajian :

BIODATA
Nama Ibu : Ny. Nama Suami : Tn.
Umur : tahun Umur : tahun
Agama : Agama :
Suku/Bangsa : Suku/Bangsa :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat :

A. DATA SUBJEKTIF
1. Alasan Datang
……………………………………………………………………………………….
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……………………………………………………………………………………….
2. Data Kebidanan
a. Riwayat Menstruasi
Menarche : tahun Sifat :
Siklus : hari Teratur/Tidak :
Lamanya : hari Warna :
Jumlah : x ganti pembalut Dismenorea :
3. Riwayat KB
Pernah Menjadi Akseptor KB :
Jenis Kontrasepsi :
Lamanya :
Masalah/Keluhan :
4. Riwayat Kesehatan
Riwayat Penyakit keturunan :
Riwayat Penyakit Menular :
5. Riwayat Perkawinan
Status Perkawinan :
Umur kawin : tahun
Lama kawin : tahun
6. Riwayat psikososial
Hubungan Ibu dan Keluarga :
Pengambilan Keputusan dalam Keluarga :
7. Data kebutuhan dasar
a. Nutrisi
1) Pola Makan
Frekuensi : x/hari
Jenis : ………………………………………………………………..
Pantangan :
2) Pola minum
Air putih : gelas/hari ( cc) Susu :
Kopi/Teh :
b. Pola Eliminasi
1) BAK
Frekuensi : x/hari Keluhan :
Warna :
2) BAB
Frekuensi : x/hari Warna :
Konsistensi : Keluhan :
3) Pola Aktivitas dan Istirahat
Tidur Malam : jam/hari
Tidur Siang : jam/hari
Aktivitas :
 4) Pola Kebersihan Diri
Mandi : x/hati
Sikat gigi : x/hari
Ganti Pakaian Dalam : x/hari
Pola Seksualitas :

B. DATA OBJEKTIF
1. Pemeriksaan Umum
Keadaan umum :
Kesadaran :
Tanda-tanda Vital
a. TD : mmHg
b. Nadi : x/menit
c. Pernafasan : x/menit
d. Suhu : °C
TB : cm
BB : kg
2. Pemeriksaan Fisik
Kepala : …………………………………………………………………….
Muka : …………………………………………………………………….
Mata : …………………………………………………………………….
Hidung : …………………………………………………………………….
Mulut : …………………………………………………………………….
Telinga : …………………………………………………………………….
Leher : …………………………………………………………………….
Payudara : …………………………………………………………………….
Abdomen : …………………………………………………………………….
Genitalia : …………………………………………………………………….
Ekstremitas Atas : …………………………………………………………….
Ekstremitas bawah : ……………………………………………………………
Pemeriksaan ginekologi
- Pemeriksaan dalam : ……………………………………………………….
- Inspekulo : ……………………………………………………….
3. Pemeriksaan laboratorium
1. Darah 2. Urine
Golongan Darah : Glukosa :
Hb : Protein :
C. ANALISA DATA
Diagnosa ………………………………………………………………………..
:
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D. PENATALAKSANAAN
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Palembang, Oktober 2022

Pembimbing Lahan Praktik Mahasiswa

Tri Wulandari
NIM PO.71.24.2.22.072

Mengetahui.
Pembimbing Institusi

Murdiningsih, SST, SPd, M.Kes

NIP 19571229 197811 2 001