YAYASAN MARANATHA

NUSA TENGGARA TIMUR

SEKOLAH TINGGI ILMU KESEHATAN MARANATHA
Jl. KAMP. BAJAWA NASIPANAF - BAUMATA BARAT–KAB. KUPANG
Telp/Fax : 0380 – 8552971 ; admin@stikesmaranathakupang.ac.id
Website : http//www.stikesmaranathakupang.ac.id

ASUHAN KEBIDANAN PADA IBU HAMIL

G.....P.....A....AH.......UK.....minggu

PENGKAJIAN
Tanggal/Jam pengkajian : Tempat pengkajian :
No.MR/Reg : Oleh mahasiswa :
BIODATA
Nama ibu : Ny. Nama suami : Tn.
Umur : Umur :
Agama : Agama :
Suku/bangsa : Suku/bangsa :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Penghasilan : Penghasilan :
Alamat rumah : Alamat rumah :

A. DATA SUBYEKTIF
 Keluhan utama /alasan
kunjungan: ...........................................................................................................
..............................................................................................................................
..................
 Riwayat haid
 Menarche :....................................................................................................
 Siklus :....................................................................................................
 Lamanya darah :.............................................................................................
 Sifat darah :.............................................................................................
 Nyeri haid :..............................................................................................
 HPHT :..............................................................................................

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  Riwayat Keluarga Berencana
KB yang pernah digunakan :
Lamanya :
Efek samping :
Alasan berhenti :

 Riwayat perkawinan
 Status perkawinan :..............................................
 Lamanya kawin :.........................................................
 Umur pada saat kawin pertama :..........................................................
 Berapa kali kawin :..........................................................
 Riwayat kehamilan yang lalu
 Apakah ada masalah,seperti :..........................................................
muntah yang berlebihan ...........................................................
Toksemia gravidarum :..........................................................
 Selama hamil periksa dimana /berapakali :.............................................

 Riwayat kehamilan sekarang

TM 1 : Kunjungan I
Keluhan :......................................................................
Terapi :......................................................................
Kunjungan II
Keluhan :......................................................................
Terapi :......................................................................
Kunjungan Lainnya :
Keluhan :......................................................................
Terapi :......................................................................
TM II Kunjungan I
Keluhan :......................................................................
Terapi :......................................................................
Kunjungan Lainnya :
Keluhan :......................................................................
Terapi :......................................................................
TM III Kunjungan I

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 Keluhan :......................................................................
Terapi :......................................................................
Kunjungan II
Keluhan :......................................................................
Terapi :......................................................................
Kunjungan III
Keluhan :......................................................................
Terapi :......................................................................
Kunjungan Lainnya :
Keluhan :......................................................................
Terapi :......................................................................

 Skrining Imunisasi Tetanus Toxoid berapa kali :..................................

T1 :*................................................................
T2 :*...............................................................
T3 :*...............................................................
T4 :*...............................................................
T5 :*...............................................................
*(Waktu mendapatkan Imunisasi)
 Pergerakan janin dirasakan pertama kali pada usia kehamilan..........bulan
 Riwayat persalinan lalu
N Tgl/bln/ Jenis U Penolong Tpt Keadaan JK BB/ KET
O thn Persalinan K (Dokter/ Pers bayi saat PB Saat
Bidan) Lahir ini/sekarang
(LH /LM )
1
2
3

 Riwayat kesehatan
 Riwayat penyakit yang diderita/saat ini termasuk (HIV, Hepatitis B,
Syphillis dan penyakit kronis lainnya)
:.....................................................................................................................
 Riwayat penyakit yang lalu :..........................................................
 Riwayat penyakit keluarga :..........................................................

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  Riwayat kesehatan dan penyakit keturunan
 Apakah ada keluarga yang menderita penyakit kronis :......................
 Apakah ada keluarga yang menderita penyakit menular :......................
 Apakah ada keturunan kembar :......................
 Keadaan psikososial
 Respon ibu dan keluarga terhadap kehamilan : ............................................
............................................................................................................................
 Dukungan dari keluarga: ............................................................................
..............................................................................................................................
 Tempat dan penolong yang diinginkan untuk Persalinan .............................
..............................................................................................................................
 Beban kerja dan kegiatan sehari-hari : ..........................................................
.............................................................................................................................
 Jenis kelamin yang diharapkan : ...................................................................
..............................................................................................................................
 Pengambil keputusan dalam keluarga: .........................................................
.............................................................................................................................
 Perilaku kesehatan
 Merokok (Pasif, Aktif) :
....................................................................
 Miras :.....................................................................
 Konsumsi obat terlarang
:......................................................................
 Minum kopi (Saat minum SF)
:...............................................................
 Latar belakang budaya
 Kebiasaan melahirkan ditolong oleh : .................................
 Pantangan makanan : .................................
 Kepercayaan yang berhub. Dengan persalinan : .................................
 Kepercayaan yang berhub. Dengan nifas : .................................
 Riwayat seksual
 Sebelum hamil : .................................................................................
 Saat hamil : .................................................................................
 Keluhan : .................................................................................
 Pola makan
Sebelum hamil Saat hamil

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 Frekuensi:
x/hari x/hari
Jenis makanan:
Keluhan
Minuman ……gelas/ hari ……gelas/ hari
Frekuensi
Keluhan

 Pola eliminasi
Sebelum hamil Saat Hamil
BAB
Frekuensi x/hari x/hari
Konsistensi
Warna:
Bau
BAK
Frekuensi: x/hari x/hari
Warna:
Bau:

 Pola istirahat/tidur
Sebelum Hamil Saat Hamil
Tidur Siang
Jam Jam
Tidur malam
Jam Jam
Keluhan

 Kebersihan diri
Sebelum Hamil Saat Hamil
Mandi
x/hr x/hr
Sikat gigi
x/hr x/hr
Ganti pakaian
x/hr x/hr
Keramas
x/mgg x/mgg
Perawata
Payudara x/mgg x/mgg

 Pengetahuan tentang (P4K): ...............................................................................

B. DATA OBYEKTIF
 Pemeriksaan umum
 Keadaan umum : .................................................................................
 Kesadaran : .................................................................................

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  Bentuk tubuh : .................................................................................
 Ekspresi wajah : .................................................................................
 Tanda-tanda vital : TD :....................... Pernapasan : ......................
Suhu :....................... Nadi : ......................
Berat badan : ................................................................................
- Sebelum hamil :
- Sekarang :
IMT Sebelum hamil :
Lila : .................................................................................
HPL :..............................................................................................
 Pemeriksaan fisik obstetrik
 Inspeksi
 Kepala : .............................................................................................
Rambut : .............................................................................................
 Wajah
Pucat : .....................................................................
Cloasma gravidarum : .....................................................................
Oedema : .....................................................................
 Mata
Conjungtiva : .................................................................................
Sklera : .................................................................................
Oedema : .................................................................................
 Telinga : ................................................................................
 Mulut dan gigi : .................................................................................
 Leher : .................................................................................
 Dada
Payudara : .....................................................................
Aerola mammae : .....................................................................
Puting susu : .....................................................................
 Abdomen
Luka bekas operasi : ....................................................................
Strie : .....................................................................
Linea : .....................................................................
 Ekstremitas : .....................................................................
 Genitalia : .................................................................................

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  Anus : .................................................................................
 Palpasi
 Leher : .............................................................................................
.......................................................................................................................
 Dada : .................................................................................
............
 Abdomen
Kontraksi :
Leopoid 1 : .................................................................................
Leopold 11 : .................................................................................
Leopold 111 : .................................................................................
Leopold 1V : .................................................................................
Mc Donald : …………………………………………………….
TBBJ : ……………………………………………………
 Auskultasi (DJJ): .............................................................................................
 Perkusi,Refleks Patella : ....................................................................
 Pemeriksaan laboratorium
 Urine
Protein urine : .................................................................................
Urine reduksi : .................................................................................
 Darah
Golongan darah:.................................................................................
HB : ................................................................................
Malaria :................................................................................
HBSAg :………………………….........................................
HIV :…………………………………………………….
Sifilis :…………………………………………………….
 Dahak
BTA :…………………………………………………….
 Pemeriksaan khusus
 USG : .............................................................................................
 Rontgen : .............................................................................................

C. ANALISA DATA
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D. PENATALAKSANAAN (Perencanaan, Pelaksanaan dan Evaluasi)

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............., .................................
Pebimbing Lahan Praktik/CI Mahasiswa

(.....................................................) (.....................................................)

Mengetahui
Pembimbing Institusi/CT

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