PENGKAJIAN ASUHAN KEBIDANAN.....

DI RS/PUSKESMAS...............................

No. Medrec : …………………….

Tgl.masuk : …………………….
Tgl & jam pengkajian : …………………….
Nama pengkaji :…

A. IDENTITAS ISTRI SUAMI

Nama : ………………………………. ..........................................

Umur : .................................................
Suku : .................................................
Agama : .................................................
Pendidikan : .................................................
Pekerjaan : .................................................
Alamat : .................................................
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No. Tlp : .................................................
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B. DATA SUBJEKTIF
1. Alasan datang ke RS/Puskesmas
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2. Keluhan utama
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3. Riwayat Obstetri.....................
Riwayat Haid
3.2.1. Menarche : …………………………………………
3.2.2. Siklus : …………………………………………
3.2.3. Lamanya : …………………………………………
3.2.4. Banyaknya : …………………………………………
3.3.5. Desmenorhoe : …………………………………………

4. Riwayat Ginekologi
4.1. Infertilitas : ....................................................................................................
4.2. Masa : ....................................................................................................
4.3. Penyakit : ....................................................................................................
4.4. Operasi : ....................................................................................................

5. Riwayat KB
5.1. Kontrasepsi yang dipakai : ............................................................................
5.2. Keluhan : ……………………………………………........
5.3. Kontrasepsi yang lalu : …………………………………………............
5.4. Lamanya pemakaian : ……………………………………………........
5.5. Alasan berhenti : ............................................................................

6. Riwayat Penyakit lainnya : …………………………………………………

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7. Pola Nutrisi : Makan : .....X/hari (teratur /tidak teratur)
Pantang makan : ................................................
 Minum : .............................................................

8. Pola Eliminasi : BAB : ..............X/hari

BAK : .............X/hari
Masalah : ............................................................................

9. Pola Tidur : Malam : ..................Jam

Siang : ..................Jam
Masalah : …………………………………………………

10. Data sosial

Dukungan Suami :……………………………………..…………...
Dukungan keluarga : ............................................................................
Masalah : …………………………………………………

C. DATA OBJEKTIF
1. Kesadaran
(__) Komposmentis
(__) Somnolent
(__) Sopor
(__) Sopor komatus
(__) Komatus

2. Tanda-tanda Vital
Nadi ……………X/mnt
Suhu …………...X/mnt
Tensi …………..mmHg
Respirasi ……….X/mnt

3. Kepala
Rambut : …………………………………………………………………
Mata : Konjungtiva : …………………………………………………
Sclera : …………………………………………………
Pengelihatan : …………………………………………………
Telinga : …………………………………………………………………
Hidung : …………………………………………………………………
…………………………………………………………………
Mulut : …………………………………………………………………
Leher : …………………………………………………………………
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4. Dada : Bentuk simetri : Ya (__) Tidak (__)

Mamae : Bentuk simetris : Ya (__) Tidak (__)
Puting Susu : ………………………………………....
Benjolan : …………………………………………
Ekskresi : …………………………………………
5. Abdomen
………………….

6. Genetalia Luar
Bentuk : …………………………………………………………………
Varices : …………………………………………………………………
Oedema : …………………………………………………………………
Massa / Kista : ....................................................................................................
Pengeluaran pervigam : .......................................................................................
7. Ekstremitas (tangan & kaki)
Bentuk : Kaki : ................................. Tangan : .......................................
Kuku : Kaki : ................................ Tangan : .......................................
8. Kulit
 Warna : ....................................
Turgor : ....................................
9. Data Penunjang (LABORATORIUM)
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 PENDOKUMENTASIAN ASUHAN KEBIDANAN ....
No. Medrec : …………………….
Tgl.masuk : …………………….
Tgl & jam pengkajian : …………………….
Nama pengkaji :…

IDENTITAS ISTRI SUAMI

Nama : ………………………………. ..........................................

Umur : .................................................
Suku : .................................................
Agama : .................................................
Pendidikan : .................................................
Pekerjaan : .................................................
Alamat : .................................................
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No. Tlp : .................................................
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SUBJEKTIF
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OBJEKTIF
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ASSESMENT
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PLANNING
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 Judul Laporan

LOGO

NAMA
NIM

SEKOLAH TINGGI ILMU KESEHATAN PELITA IBU

PRODI PENDIDIKAN PROFESI BIDAN
SAMPUL
LEMBAR PENGESAHAN
KATA PENGANTAR
DAFTAR ISI

BAB I. PENDAHULUAN
A. Latar Belakang
B. Rumusan Masalah
C. Tujuaa

BAB II TINJAUAN PUSTAKA

A. Tinjauan Umum...
B. Tinjauan Khusus...(Sesuai kasus)
PENGKAJIAN ASUHAN KEBIDANAN
PENDOKUMENTASIAN ASUHAN KEBIDANAN

BAB III PENUTUP

A. Kesimpulan
B. Saran

DAFTAR PUSTAKA
LAMPIRAN (FOTO)