FORMAT PENGKAJIAN DATA ASUHAN KEBIDANAN PADA

PERSALINAN
PROGRAM STUDI PROFESI BIDAN FAKULTAS KEBIDANAN DAN
KEPERAWATAN UNIVERSITAS KADER BANGSA PALEMBANG
Jalan Mayjend H.M. Ryacudu N0.88Telp.(0711)517744-510173
Fax(0711)519827 Email: Info@ukb.ac.id
Website: www.ukb.ac.id

Manajemen Asuhan Kebidanan Persalinan Pada Ny”..” G…P…A..H..

Usia Kehamilan……… Minggu Normal / Dengan ………..Di
………………………………………….
Pada Tanggal ……………………………………….

Tempat Praktek/Ruang : ……………………………………………

………
Nomor MR : …………………………
Masuk RS/PMB/Klinik : ………………………………………
Pembimbing lahan/CI : …………………………………………
Pengkajian tanggal : ……………………… Jam ………… Oleh……..
Sumber data : ………………………………………………

I. PENGKAJIAN DATA
1. Identitas
a. Identitas Pasien
a. Nama : …………………… a. Nama : ……………………
b. Umur : ……………………. b. Umur : ………………
c. Agama : ……………………. c. Agama : ……………….
d. Suku/bangsa : ……………………. d. Suku/bangsa : ……………….
e. Pendidikan : ……………….. e. Pendidikan : ……………
f. Pekerjaan : …………………… f. Pekerjaan : ………………
g. Alamat : ……………… g. Alamat : ………………
h. No telp/HP : ………………… h. No telp/HP : …………………

1. Anamnesa Data Subjektif

a. Alasan Kunjungan dan Keluhan Utama :……………………………………………………
…………………………………………………………………………………………………………………
……………………………………

b. Riwayat Menstruasi :
- Menarche : Umur : …..tahun, teratur / tidak teratur
- Siklus Haid : …….hari, Lamanya :…..hari
 - Banyaknya : ........x Ganti Pembalut
c. HPHT : ………………………………………..
d. TP : ………………………………………..
e. Riwayat Kehamilan, Persalinan dan Nifas yang lalu :

Tgl Jenis Bayi Nifas

N Usia Komplikasi
Lahir / Persalin Penolong Asi Ekslusif
o Kehamilan P J
Umur an BB Keadaan Keadaan
Ibu Bayi B K Ya Tidak

f. Riwayat Hamil ini :

Keluhan yang dirasakan ibu :
- TM I : ……………………………………………
- TM II : …………………………………………………
- TM III : ………………………………………………..
Pemeriksaan ANC : ………………………………………………...
Pergerakan janin pertama kali dirasakan ibu : ……………………..
Ibu ada mengkonsumsi tablet Fe : …………………….. a.
g. Imunisasi TT : TT1……… TT2 :……………, TT3 :…………………. b.
h. Riwayat Keluarga Berencana : ………………………………………… c.
i. Riwayat Kesehatan :
Riwayat Kesehatan Lalu :
Jantung : ………………………………………………..
Asma : ……………………………………………..
Tuberculosis : ……………………………………………..
Ginjal : ……………………………………………..
Diabetes Militus : ………………………………………………..
Malaria : ……………………………………………….
HIV/AIDS : ………………………………………………

Riwayat Kesehatan Sekarang :

Jantung : ………………………………………………
Asma : ………………………………………………
Tuberculosis : …………………………………………………
Ginjal : ………………………………………………
Diabetes Militus : …………………………………………………
Malaria : ………………………………………………
HIV/AIDS : ………………………………………………
 Riwayat Kesehatan Keluarga :
Jantung : ……………………………………………
Asma : …………………………………………
Tuberculosis : ………………………………………………
Ginjal : ……………………………………………
Diabetes Militus : ………………………………………..…
Malaria : …………………………………………..…
HIV/AIDS : ………………………………………………
Riwayat Kebiasaan ( Merokok, Jamu, Alkohol dll) : ………….
j. Riwayat Kebiasaan dan Psikososial :
1) Kebiasaan
a) Diet / makan :
Makan pagi : ………………………………………………
Makan Siang : ………………………………………………
Makan malam : ……………………………………………...
Minum sehari – hari :………………………………………...
b) Pola Eliminasi
BAB
- Frekuensi : ……kali sehari
- Konsistensi : ………………..
- Warna : ………………..
- Masalah : …………………
BAK
- Frekuensi : …….. kali sehari
- Warna : …………………
- Bau : …………………
- Masalah : …………………
c) Aktivitas sehari-hari : …………………………………………
d) Pola Istirahat dan Tidur :
Siang hari : …….jam
Malam hari : …….jam
e) Personal Hygiene : Ibu ada mandi ….. kali sehari, gosok gigi
……kali sehari dan ganti pakaian : … sehari
f) Pola seksualnya : ………………………………………………
2) Riwayat Sosial budaya : ………………………………………….
3. Pemeriksaan Fisik (Data Objektif)
a. Pemeriksaan Umum
1) Keadaan Umum : ………………………………………………..
2) BB Sebelum Hamil :…….. kg
3) BB hamil sekarang : ……..Kg
4) Lila : ….. cm
5) Tinggi Badan : ……. cm
6) Tanda- tanda Vital :
TD : ………………mmHg
Nadi : ……. x/i
Pernafasan : ……...x/i
Suhu : ………oC
b. Pemeriksaan Sistematis / Inspeksi :
1) Kepala :
- Rambu : ……………………………………………………
- Muka : ……………………………………………………
- Mata : ……………………………………………………
- Hidung : ……………………………………………………
- Mulut : ……………………………………………………
- Telinga : ……………………………………………………
2) Leher : ……………………………………………………
3) Dada :…………………………………………………….
4) Payudara : ……………………………………………………
5) Axilla : ……………………………………………………………
6) Ekstremitas atas :
a) Oedema : ……………………………………………………
b) Varices : ……………………………………………………
c) Kuku : ……………………………………………………
7) Ekstremitas bawah :
a. Oedema : ……………………………………………………
b. Varices : ……………………………………………………
c. Kuku : ……………………………………………………
c. Pemeriksaan Khusus Obstetri :
1) Abdomen :
a) Inspeksi : ………………………………………………….
b) Palpasi : LI :
……………………………………………………
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 LII :
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LIII :
…………………………………………………
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LIV :
…………………………………………………
…………………………………………………
…………………………………………………
…………………………………………………
Taksiran Berat Janin (TBJ) : (…………..)x155
= ……. gram.
c) Auskultasi : (+)……x/i, Intensitas : ……., Irama : …
: Puntum maximum : ……………………
d) Ano-genital : ……………………………………………
e) Vagina : …………………………………………….
f) Perkusi : Reflek patella Ka/Ki (…/…..)
g) Pemeriksaan Panggul Luar :
Distansia Spinarum : …….. cm
Distansia Cristarum : …….. cm
Konjugata Eksterna : …….. cm
Lingkar Panggul : …….. cm
 h) Pemeriksaan Panggul Dalam : Pukul : .............................................
1) Dilakukan Oleh ......................................................................
2) Pukul ......................................................................................
3) Indikasi...................................................................................
4) Hasil :
a. Portio ..........................................................................
b. Pembukaan .................................................................
c. Ketuban .....................................................................
d. Presentasi ..................................................................
e. Penurunan .................................................................
f. Pendataran ..................................................................
g. Molase .......................................................................

i) Pemeriksaan Laboratorium / penunjang :

HB : gr%
Protein Unrine : ………
Glukosa Urine : ……….
II. PERUMUSAN DIAGNOSA , DIAGNOSA POTENSIAL, MASALAH DAN
KEBUTUHAN
Diagnosa………………………………………………………………………
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Diagnosa Potensial …………………………………………………………

Masalah………………………………………………………………………
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Kebutuhan
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III. PERENCANAAN
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V. EVALUASI

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ASUHAN KALA II

Tanggal :
Pukul :
I. PENGKAJIAN
a. Data Subjektif ....................................................................................
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b. Data Objektif......................................................................................
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 II. PERUMUSAN DIAGNOSA, DIAGNOSA POTENSIAL, MASALAH
DAN KEBUTUHAN
Diagnosa ...................................................................................................
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Diagnosa Potensial ....................................................................................
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Masalah .....................................................................................................
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V. EVALUASI
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ASUHAN KALA III

Tanggal :
Pukul :
I. PENGKAJIAN
a. Data Subjektif
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b. Data Objektif .......................................................................................
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II. PERUMUSAN DIAGNOSA, DIAGNOSA POTENSIAL,

MASALAH DAN KEBUTUHAN
Diagnosa ...................................................................................................
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Diagnosa Potensial ....................................................................................
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Masalah .....................................................................................................
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 V. EVALUASI
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ASUHAN KALA IV

Tanggal :
Pukul :
I. PENGKAJIAN
1. Data Subjektif ....................................................................................
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2. Data Objektif......................................................................................
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II. PERUMUSAN DIAGNOSA, DIAGNOSA POTENSIAL, MASALAH

DAN KEBUTUHAN
Diagnosa ...................................................................................................
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Diagnosa Potensial ....................................................................................
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Masalah .....................................................................................................
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V. EVALUASI
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 MONITORING ASUHAN KEBIDANAN PERSALINAN
PADA………………………….USIA KEHAMILAN …… MINGGU DI PMB
………………………………………………………………...

WAKTU MONITORING ASUHAN PERSALINAN TTD

S:

O:

A:

P:

Pembimbing Akademik Pembimbing Klinik Mahasiswa

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