SEKOLAH TINGGI ILMU KESEHATAN

KAPUAS RAYA SINTANG

Alamat : Jl. DR.Wahidin Sudirohusodo No.80,Kodepos 78612
Telp/Fax. (0565) 2025099, Email: stikeskr@ymail.com | www.stikes-kapuasraya.ac.id

SK. MENDIKNAS RI. No. 117/D/O/2009, Tanggal. 3 Agustus 2009 | DEPKES RI. Kode Institusi 61072401S, Tanggal. 7 Oktober 2009

ASUHAN KEBIDANAN PADA KELUARGA BERENCANA

NAMA MAHASISWA : ............................................................................................................
NIM : ............................................................................................................
TEMPAT PRAKTEK : ............................................................................................................
NOMOR RM : ............................................................................................................

I. PENGKAJIAN
A. IDENTITAS
Nama Ibu : ............................................. Nama Suami : .......................................................
Umur : ............................................. Umur : .......................................................
Agama : ............................................. Agama : .......................................................
Suku / Bangsa : ............................................. Suku / Bangsa : .......................................................
Pendidikan : ............................................. Pendidikan : .......................................................
Pekerjaan : ............................................. Pekerjaan : .......................................................
Status Perkawinan : Ya/Tidak Lamanya : ..........Tahun
Alamat Rumah : .............................................................................................................................................
No HP / Telp : .............................................

B. KELUHAN UTAMA
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C. RIWAYAT KESEHATAN
1. Riwayat haid
a. Menarce : ...............tahun
b. Siklus : Teratur / tidak, ..............hari
c. Lamanya : ...............hari
d. Masalah : .............................................................................................................................................
e. Haid terakhir : .............................................................................................................................................

2. Riwayat anak
a. Jumlah anak yang hidup : ..............................................................................................................................
b. Jumlah anak lahir mati : ...............................................................................................................................
c. Umur anak terkecil : ..................... tahun

3. Riwayat persalinan dan nifas yang lalu

a. Masalah dalam setiap persalinan : .................................................................................................................
........................................................................................................................................................................
b. Masalah dalam setiap masa nifas / meneteki : ...............................................................................................
.........................................................................................................................................................................

4. Riwayat menyusui (saat ini)

a. Menyusui : ya / tidak
b. Penggunaan PASI : ..............................................................................................................................

5. Riwayat kontrasepsi yang lalu

a. Metode yang di gunakan : .............................................................................................................................
b. Sejak : ............................................................................................................................................................
c. Efek samping dari metode tersebut : .............................................................................................................
d. Drop out / lepas KB tersebut sejak : ................................................................................................................................
e. Rencana metode KB yang akan di gunakan : ................................................................................................
6. Riwayat pengobatan / rokok / alkohol :
 a. Obat yang pernah / yang sedang digunakan : ...............................................................................................
b. Ketergantungan dengan rokok : ya / tidak
Berapa banyak per hari : ...............................................................................................................................
c. Ketergantungan dengan alkohol : ya / tidak
Berapa banyak per hari : ...............................................................................................................................
7. Riwayat atau masalah kesehatan yang lalu : ........................................................................................................
...............................................................................................................................................................................

8. Riwayat atau masalah kesehatan saat ini

a. Hipertensi : ya / tidak
b. Pusing / sakit kepala yang hebat : ya / tidak
c. Infeksi vagina / PID : ya / tidak
d. Perdarah ginekologi ( tidak di ketahui penyebabnya) : ya / tidak
e. Keputihan yang hebat : ya / tidak
f. Anemia : ya / tidak
g. Alergi : ya / tidak
h. Jantung : ya / tidak
i. Tumor : ya / tidak
j. Diabetes militus : ya / tidak
k. Riwayat kehamilan ektopik : ya / tidak
l. Nyeri pada tungkai bawah : ya / tidak

9. Pengetahuan pasien tantang KB :

a. Manfaat KB : ..................................................................................................................................................
.........................................................................................................................................................................
b. Metode / jenis alat kontrasepsi : ......................................................................................................................
........................................................................................................................................................................
c. Kelemahan / kelebihan masing-masing metode : ............................................................................................
.........................................................................................................................................................................
d. Sarana pelayanan KB : ...................................................................................................................................
e. Indikasi dan kontra indikasi masing-masing metode : ....................................................................................
.........................................................................................................................................................................
f. Kemungkinan efek samping : .........................................................................................................................
g. Metode / jenis yang dipilih klien & pasangan : ..............................................................................................

D. PEMERIKSAAN FISIK
1. Tinggi badan : ......................cm
2. Berat badan : ......................kg
3. Tanda-tanda vital
TD : .....................mmHg Nadi : .............................. x/menit
RR : .................X / menit Suhu : ............................. 0C

4. Kulit
a. Warna : ...............................
b. Turgor : ...............................
5. Rambut
a. Warna : .................................
b. Kebersihan : .................................
c. Lain-lain : .................................
6. Muka
a. Oedem : ..................................
b. Hiperpigmentasi : ...............................
c. Lain-lain : ..................................
7. Mata
a. Konjungtiva : ..................................
b. Sklera : ..................................
c. Lain-lain : ..................................
8. Gigi dan mulut
a. Oral hygine : .................................
b. Masalah : .................................
9. Leher
a. Kelenjar thyroid : teraba membesar / tidak
b. Vena jugularis : membesar / tidak
10. Dada
 a. Bentuk : simetris / tidak
b. Auskultasi
- Paru : .................................
- Jantung : .................................
c. Buah dada
- Bentuk : simetris / tidak
- Konsistensi : lembut / keras
- Pembesaran : ya / tidak
- Teraba benjolan : ya / tidak
- Pengeluaran ASI : ya / tidak

11. Abdomen
a. Pembesaran : ya / tidak
b. Hepar : teraba / tidak
c. Pembesaran uterus : ya / tidak
d. Lain-lain : ...............................

12. Ekstremitas
a. Oedem : ya / tidak
b. Varises : ya / tidak
c. Nyeri : ya / tidak

13. Vulva / vagina

a. Pengeluaran : ya / tidak
b. Bau : ya / tidak

14. Pemeriksaan dalam (bila dilakukan)

a. Posisi rahim : ...............................................................................................................................
b. Pembesaran rahim : ya / tidak
c. Konsistensi rahim : ...............................................................................................................................
d. Ukuran rahim : ...............................................................................................................................
e. Keadaan porsio : ...............................................................................................................................
f. Kelainan / masalah : ...............................................................................................................................

E. PEMERIKSAAN PENUNJANG / LABORATORIUM (bila dilakukan)

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

II. INTERPRETASI DATA

Diagnosa ibu
:............................................................................................................................................... .........................
.......................................................................................................................
Dasar : .............................................................................................................................................
.............................................................................................................................................

III. DIAGNOSA MASALAH POTENSIAL

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Dasar : .........................................................................................................................................................
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IV. ANTISIPASI TINDAKAN SEGERA
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V. PERENCANAAN TINDAKAN
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VI. PELAKSANAAN

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VII. EVALUASI

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Mahasiswa
CI/Pembimbing Lahan

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

Pembimbing Akademik

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