LAPORAN KEGIATAN

Pre Praktik Klinik Kebidanan ( Pre PKK)

Di Rumah Bersalin, Bidan Praktik Swasta, Bidan praktik Mandiri

TANGGAL 10 Januari-2 Februari 2022

IDENTITAS MAHASISWA
NAMA :
NIM :
Tingkat / Semester :

AKADEMI KEBIDANAN St. BENEDICTA PONTIANAK

TINGKAT 2 SEMESTER 3
 SURAT PERNYATAAN PEMBIMBING CI LAHAN PRAKTIK
AKADEMI KEBIDANAN St. BENEDICTA PONTIANAK

Yang bertanda tangan di bawah ini :

NAMA :
TTL :
PENDIDIKAN TERAHIR :
ALAMAT :
JABATAN :
INSTANSI :
Dengan ini menyatakan, BERSEDIA/TIDAK BERSEDIA sebagai CI Lahan pada
PRAKTIK KLINIK KEBIDANAN PRE PKK mahasiswa Tingkat 2 Semester 3
Akademi Kebidaan St. Benedicta Pontianak

Pontianak, 2022
Yang menyatakan

(.......................................)
 SURAT KETERANGAN PENGGANTIAN DINAS

Dengan ini kami menerangkan bahwa:

Nama Mahasiswa :
NIM :
Tempat Dinas :

Adapun jadwal penggantian dinas yang akan dilaksanakan oleh mahasiswa akan
dilaksanakan Selama …. Hari, tanggal penggantian dinas sbb:

No Tanggal Dinas (Sesuai Jadwal) Tanggal Penggantian Keterangan

1
2
3
4
5
6
7
8
9
10
11
12
13
14

Demikian surat keterangan ini kami sampaikan, Atas perhatian dan kerjasamanya kami
ucapkan terima kasih

Mengetahui,

Pimpinan,

(……………………………………)
 LAPORAN KEGIATAN HARIAN MAHASISWA
PRAKTIK PRE PKK
Tempat Praktik : Puskesmas
Periode Waktu Praktik:
Ruangan :
Nama Mahasiswi :
NIM :
Hari/Tanggal :
Shift :

TANDA TANGAN
NAMA DATA YANG DIAGNOSA/
NO TANGGAL UMUR TINDAKAN BANTU MANDIRI PEMBIMBING
PASIEN DITEMUKAN MASALAH MAHASISWA
LAHAN

Pembimbing Akademik Pembimbing Lahan

( ) ( )
 REKAPITULASI PEROLEHAN TARGET ASUHAN KEBIDANAN PRE PKK

KASUS KEGIATAN JUMLAH TARGET YANG

DIPEROLEH
Asuhan Kebidanan Kehamilan
Asuhan Kebidanan Persalinan
Asuhan Kebidanan Nifas
Asuhan Kebidanan Bayi Baru Lahir
Asuhan Kebidanan Balita Sakit
Asuhan Kebidanan Balita Sehat

Pontianak, Agustus 2022

Pembimbing Akademik Pembimbing Lahan Praktik

( ) ( )
NIDN :
 LEMBAR KONSULTASI LAPORAN ASUHAN KEBIDANAN

Nama Mahasiswa :
NIM :
Semester :
Tempat Praktik :
Nama CI Lahan :
Nama Pembimbing Akademik :
Periode Praktik :

TANDA TANGAN
NO TANGGAL MATERI BIMBINGAN
PEMBIMBING
 Pontianak, Agustus 2022
Pembimbing Akademik Pembimbing Lahan Praktik

( ) ( )
NIDN :
 ASUHAN KEBIDANAN IBU HAMIL NORMAL
PADA NY…. DENGAN UMUR KEHAMILAN….mg DI BPS….

Pengkajian Data
Dilakukan tgl………………….pukul…………...WIB

I. PENGKAJIAN DATA
DATA SUBYEKTIF
1. Biodata

Nama Ibu : …… Nama Suami :…. ..

Umur : ……thn Umur : ..……thn
Suku/bangsa : …… Suku/Bangsa : .........
Agama : …… Agama : .........
Pendidikan : …… Pendidikan : …….
Pekerjaan : …… Pekerjaan : ……
Alamat Rumah : …… Alamat Kantor : ……

2. Keluhan utama/ alasan datang ............................................................................

3. Riwayat Kesehatan
a. Riwayat Kesehatan ibu: (penyakit menular, menurun dan menahun)
Dahulu :…………………………………………………………………………………

Sekarang :…………………………………………………………………………………

b. Riwayat Kesehatan keluarga :……………………………………………………………………

c. Rriwayat keturunan kembar :…………………………………………………………………..

4. Riwayat Perkawinan.........................................................

5. Riwayat Obstetri
Menarche :
Siklus :
Lamanya :
Konsistensi:
Keluhan/ gangguan :
HPHT :
HPL :
Riwayat kehamilan, persalinan dan nifas yang lalu:
anak
Thn Jenis Masalah/
NO Tempat Penolong Jenis
persalinan pesalinan gangguan BB/PB Ket
kelamin
1
2
3
4
5

6. Riwayat KB

Thn Tempat &

NO Jenis Alkon Thn berhenti Alasan berhenti
mulai penolong
1
2
3
4
5

1
7. Riwayat kehamilan sekarang
Umur kehamilan menurut ibu......................
Terapi yang pernah diberikan bidan..............
Imunisasi TT...................pada umur kehamilan...................
Kebiasaan minum jamu.........
Keluhan saat hamil Trimester I, II dan III.................

8. Riwayat pengobatan / rokok/ alkohol

Obat yang pernah dan sedang digunakan:.............
Tujuan pengobatan:..............
Cara pemberian:....................

9. Pola kebutuhan Sehari-hari

No Kegiatan Sebelum hamil Saat hamil

1. Nutrisi
a. makan
Frekuensi
Porsi
Jenis
Keluhan
b. minum
Frekuensi
Porsi
Jenis
Keluhan
2. Eliminasi
a. BAK
Frekuensi
Konsistensi
Warna
Bau
Keluhan
b. BAB
Frekuensi
Konsistensi
Warna
Bau
Keluhan
3. Pola Istirahat
Tidur malam ......jam
Tidur siang .....jam
4. Pola Aktivitas
Didalam rumah
Di luar rumah
5. Personal hygiene
Mandi
Gosok gigi
Keramas
Ganti baju
6. Seksual
Frekuensi
Keluhan

10. Pola Psikososial Spiritual

a. Tanggapan ibu terhadap kehamilannya................
b. Tanggapan keluarga terhadap kehamilan ibu................
c. Tingkat pengetahuan ibu tentang kehamilan...............
d. Ketaatan beribadah.................
e. Pengambil keputusan...................
f. Lingkungan.......................

DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum: BB sebelum hamil :.............kg
Kesadaran: BB selama hamil :.............kg
o
Tanda vital: TD.... .......mmHg, Suhu......... C, Nadi.........x/menit, Respirasi.........x/menit

2
2. Pemeriksaan status present
Kepala :…………………………………………………………………………………………
Rambut : ………………………………………………………………………………………
Muka : ………………………………………………………………………………………
Mata : ………………………………………………………………………………………
Hidung : ………………………………………………………………………………………
Mulut : ………………………………………………………………………………………
Telinga : ………………………………………………………………………………………
Leher : ………………………………………………………………………………………
Dada : ………………………………………………………………………………………
Payudara : ………………………………………………………………………………………
Abdomen : ………………………………………………………………………………………
Genitalia : ………………………………………………………………………………………
Anus : ………………………………………………………………………………………
Ekstermitas: ………………………………………………………………………………………
3. Pemeriksaan status obstetrik
Leopold I : ………………………………………………………………………………………
Leopold II : ………………………………………………………………………………………
Lopold III : ………………………………………………………………………………………
Leopold IV: ………………………………………………………………………………………
TBBJ :.............gram
DJJ :............x/menit
4. Pemeriksaan Penunjang
a. Laboratorium
Darah : Hb : ……… gram %
Urine : Protein : ………………...
Reduksi : ………………...
Glukosa : ………………...
Ph : ………………...
PP Test : Positif / Negatif
b. USG
…………………………………………………………………………………………
…………………………………………………………………………………………

II. INTERPRETASI DATA (Interpretasi data untuk mengidentifikasi diagnosa / masalah)

Diagnosa kebidanan:

Masalah :
Kebutuhan :

III. DIAGNOSA POTENSIAL ( diagnosa potensial dan cara mengatasi/ cara penanganannya)

IV. TINDAKAN SEGERA tgl...........jam........(menetapkan kebutuhan terhadap tindakan segera)

V. PERENCANAAN tgl...........jam........ (menyusun rencanan asuhan yang menyuluh)

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VI. PELAKSANAAN tgl...........jam........ (pelaksanaan langsung asuhan efisien dan aman)

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VII. EVALUASI tgl...........jam........(evaluasi hasil pelaksanaan)

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PEMBIMBING AKADEMIK

( )
MAHASISWI PEMBIMBING

( ) ( )
NIM. NIP.

4
 ASUHAN KEBIDANAN IBU BERSALIN NORMAL
PADA NY.....…. DENGAN UMUR KEHAMILAN.....….mg DI ........…........
Pengkajian Data Dilakukan Tanggal…………. Pukul………..Wib
LANGKAH I : PENGKAJIAN DATA
DATA SUBYEKTIF
1. Biodata
Nama Ibu : ………. Nama Suami :………...
Umur : …….....thn Umur : ..……....thn
Suku/bangsa : ……..... Suku/Bangsa : ..............
Agama : ……..... Agama : ..............
Pendidikan : ……..... Pendidikan : ……......
Pekerjaan : ……..... Pekerjaan : …….......
Alamat Rumah : ……..... Alamat Kantor : …….......
2. Keluhan utama/ alasan datang ....................................................................................................
3. Riwayat Kesehatan
a. Riwayat Kesehatan ibu: (penyakit menular, menurun dan menahun)
Dahulu :……………………………………………………………………………..
……………………………………………………………………………..
Sekarang :……………………………………………………………………………..
……………………………………………………………………………..
b. Riwayat Kesehatan keluarga :…………………………………………………………….
……………………………………………………………..
c. Rriwayat keturunan kembar :……………………………………………………………..
4. Riwayat Perkawinan.....................................................................................
5. Riwayat Obstetri
Menarche :.........tahun
Siklus :.........hari
Lamanya :…….hari
Konsistensi:
Keluhan/ gangguan :
HPHT :
HPL :
Riwayat kehamilan, persalinan dan nifas yang lalu:
Thn Jenis Masalah/ Anak
NO Tempat Penolong
Persalinan Pesalinan gangguan JK BB/PB Ket
1
2
3
4
5

6. Riwayat KB
Thn Thn Tempat &
NO Jenis Alkon Alasan berhenti
mulai behenti penolong
1
2
3
4
5

1
7. Riwayat kehamilan sekarang
Umur kehamilan menurut ibu......................
Terapi yang pernah diberikan bidan..............
Imunisasi TT...................pada umur kehamilan...................
Kebiasaan minum jamu.........
Keluhan saat hamil
- Trimester I :………………
- Trimester II :………………
- Trimester III :…….................
Keluhan utama
Kontraksi : Mulai sejak tanggal : Jam :
Teratur : Ya / Tidak
Frekuensi : kali, setiap 10 menit
Lamanya : detik
Pergerakan janin 24 jam terakhir : kali
Pengeluaran
Darah Lendir : Mulai sejak tanggal : Jam :
Air Ketuban : Mulai sejak tanggal : Jam :
Darah Encer : Mulai sejak tanggal : Jam :
Mekonium : Mulai sejak tanggal : Jam :

8. Riwayat pengobatan / rokok/ alkohol

Obat yang pernah dan sedang digunakan:.............
Tujuan pengobatan:..............
Cara pemberian:....................

9. Pola kebutuhan Sehari-hari

No Kegiatan Sebelum hamil Saat hamil
1. Nutrisi
a. makan
Frekuensi
Porsi
Jenis
keluhan
Terakhir makan
b. minum
frekuensi
Porsi
Jenis
keluhan
Terakhir minum
2. Eliminasi
a. BAK
Frekuensi
Konsistensi
Warna
Bau
keluhan
Terakhir BAK
b. BAB
Frekuensi
Konsistensi
Warna
Bau
keluhan
Terakhir BAB
3. Pola Istirahat
Tidur malam
Tidur siang

2
 4. Pola Aktivitas
Didalam rumah
Di luar rumah
5. Personal hygiene
Mandi
Gosok gigi
Keramas
Ganti baju
6. Seksual
Frekuensi
Keluhan

10. Pola Psikososial Spiritual

a. Tanggapan ibu terhadap kehamilannya................
b. Tanggapan keluarga terhadap kehamilan ibu................
c. Tingkat pengetahuan ibu tentang kehamilan...............
d. Ketaatan beribadah.................
e. Pengambil keputusan...................
f. Lingkungan.......................

DATA OBYEKTIF

1. Pemeriksaan umum
Keadaan umum: BB sebelum hamil :.............kg
Kesadaran: BB selama hamil :.............kg
Tanda vital: TD.... .......mmHg, Suhu.........o C, Nadi.........x/menit, Respirasi.........x/menit
2. Pemeriksaan status present
Kepala :……………………………………………………………………………………………
Rambut : ……………………………………………………………………………………………
Muka : ……………………………………………………………………………………………
Mata : ……………………………………………………………………………………………
Hidung : ……………………………………………………………………………………………
Mulut : ……………………………………………………………………………………………
Telinga : ……………………………………………………………………………………………
Leher : ……………………………………………………………………………………………
Dada : ……………………………………………………………………………………………
Payudara : ……………………………………………………………………………………………
Abdomen : ……………………………………………………………………………………………
Genitalia : ……………………………………………………………………………………………
Anus : ……………………………………………………………………………………………
Ekstermitas: ……………………………………………………………………………………………

3. Pemeriksaan status obstetrik

Leopold I : ……………………………………………………………………………………………
Leopold II : ……………………………………………………………………………………………
Lopold III : ……………………………………………………………………………………………
Leopold IV: ……………………………………………………………………………………………
TBBJ :.............gram
DJJ :............x/menit
Pemeriksaan dalam :................................................................................................................................
.................................................................................................................................

4. Pemeriksaan Penunjang
a. Laboratorium
Darah : Hb : ……… gram %
Urine : Protein : ………………...
Reduksi : ………………...
Glukosa : ………………...
Ph : ………………...

3
 b. USG
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………

LANGKAH II : INTERPRETASI DATA (Interpretasi data untuk mengidentifikasi diagnosa / masalah)

Diagnosa kebidanan:

Masalah :
Kebutuhan :

LANGKAH III : DIAGNOSA POTENSIAL ( diagnosa potensial dan cara mengatasi/ cara
Penanganannya)

LANGKAH IV : TINDAKAN SEGERA tgl...........jam........(menetapkan kebutuhan terhadap tindakan

segera)

LANGKAH V : PERENCANAAN tgl...........jam........ (menyusun rencanan asuhan yang menyuluh)

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LANGKAH VI : PELAKSANAAN tgl...........jam........ (pelaksanaan langsung asuhan efisien dan aman)

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LANGKAH VII : EVALUASI tgl...........jam........(evaluasi hasil pelaksanaan)

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4
KALA II

S : ...........................................................................................................................................
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O : ...........................................................................................................................................
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A : ...........................................................................................................................................
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P : ...........................................................................................................................................
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KALA III

S : ...........................................................................................................................................
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O : ...........................................................................................................................................
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A : ...........................................................................................................................................
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P : ...........................................................................................................................................
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KALA IV

S : ...........................................................................................................................................
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A : ...........................................................................................................................................
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P : ...........................................................................................................................................
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PEMBIMBING AKADEMIK

( )

MAHASISWI PEMBIMBING LAPANGAN

( ) ( )
NIM. NIP.

7
 LEMBAR OBSERVASI
NAMA : Ny………………………. G: P: A: M:

UMUR :……………Tahun

HARI/TGL WAKTU TTV DJJ KONTRAKSI KETERANGAN

HARI/TGL WAKTU TTV DJJ KONTRAKSI
KETERANGAN
 ASUHAN KEBIDANAN BAYI BARU LAHIR NORMAL
PADA BAYI NY…. DI............
Pengkajian Data
Dilakukan tgl……..pukul……

LANGKAH I : PENGKAJIAN DATA

DATA SUBYEKTIF
1. Biodata bayi
Nama bayi : ……………………….
Anak Ke : ……………………….
Umur Bayi : ……………………….
Tgl / jam lahir : ……………………….
Jenis Kelamin : ……………………….
2. Biodata Orang tua
Nama Ibu : …… Nama Bapak :….
Umur : ……thn Umur : ..……thn
Suku/bangsa : …… Suku/Bangsa : .........
Agama : …… Agama : .........
Pendidikan : …… Pendidikan : …….
Pekerjaan : …… Pekerjaan : ……
Alamat Rumah : …… Alamat Kantor : ……
Telp :.........
3. Riwayat Kehamilan
Usia kehamilan : ………………………minggu
Terapi yang diberikan pd saat hamil : ………………………............
4. Riwayat penyakit selama kehamilan
Perdarahan :……………………................
Preeklamsi :…………………….................
Eklamsi :……………………..................
Penyakit lain dalam kehamilan :………….........
5. Kebiasaan waktu hamil
Makan: porsi….................frekuensi...............jenis.........
Minum: porsi....................frekuensi................jenis........
Kebiasaan minum jamu :..................
Alhokol :..................
obat-obataan :…………..
6. Riwayat persalinan
Jenis persalinan :………………………………………
Ditolong oleh : ………………………………………
Lama persalinan
Kala I : ……… Jam ………. Menit
Kala II : ……… Jam ………. Menit
Ketuban
Pecah : Spontan / Amniotomi
Warna : ………….. Bau / Tidak
Jumlah : ………….. cc.
Pengobatan / Anastesi selama persalinan : ……………………………………….
Komplikasi persalinan
Ibu : ……………………………………………………………………….
Bayi : ……………………………………………………………………….
7. Pola Kebutuhan sehari-hari
Nutrisi : ………………………………………
Eliminasi BAB dan BAK:………………………..
Mekonim keluar/tidak, Pukul................Wib
DATA OBYEKTIF
1. Keadaan Bayi Baru Lahir
Nilai APGAR
KRITERIA 1 Menit 5 Menit
1. Denyut jantung
2. Usaha bernafas
3. Tonus otot
4. Refleks
5. Warna kulit
TOTAL

Resusitasi
Pengisapan lendir : ………… Rangsangan : …………
Ambu : ………… Lamanya : …………. Menit
Massage jantung : ………… Lamanya : …………. Menit
Intubasi endotrakeal : ………… Lamanya : …………. Menit
Oksigen : ………… Lamanya : …………. Menit
Terapi : ………… Lamanya : …………. Menit
Keterangan : ………… Lamanya : …………. Menit
2. Keadaan Umum
Kesadaran : ……………………….
PB : ……………… cm BB : ……………… gram
LK :……………….cm LD : ……………….cm
Tanda – tanda vital
Denyut jantung : ……… x / menit Sifat : ……………………
Pernafasan : ……… x / menit Sifat : ……………………
Suhu axilla : …………….. CO

3. Pemeriksaan fisik
Kepala : ………………………………………………………………………………
Muka : ………………………………………………………………………………
Ubun – ubun : ………………………………………………………………………………
Mata : ………………………………………………………………………………
Telinga : ………………………………………………………………………………
Mulut : ………………………………………………………………………………
Hidung : ………………………………………………………………………………
Leher : ………………………………………………………………………………
Dada : ………………………………………………………………………………
Abdomen :……………………………………………………………………………….
Tali pusat : ………………………………………………………………………………
Punggung : ………………………………………………………………………………
Ekstremitas : ………………………………………………………………………………
Genetalia : ………………………………………………………………………………
Anus : ………………………………………………………………………………
4. Refleks
Refleks Morro : ……………………................................................................................
Refrleks Rooting : ……………………................................................................................
Refleks Walking : ……………………...............................................................................
Refleks Graphs : ……………………...............................................................................
Refleks Sucking : ……………………...............................................................................
Refleks Tonic Neck : ……………………...............................................................................

5. Pemeriksaan Laboratorium
Hb : ……….. mg / dl Ht :………….% Billrubin : ………… mg / dl
GDS : ………...Mg / dl Gol, Darah : ………… Rh : …………
Lain – lain : ……………………………………………………………………………………

LANGKAH II : INTERPRETASI DATA (Interpretasi data untuk mengidentifikasi diagnosa / masalah)

Diagnosa kebidanan:

Masalah :

Kebutuhan :

LANGKAH III : DIAGNOSA POTENSIAL ( diagnosa potensial dan cara mengatasi/ cara
Penanganannya)
LANGKAH IV : TINDAKAN SEGERA tgl...........jam........(menetapkan kebutuhan terhadap tindakan
segera)

LANGKAH V : PERENCANAAN tgl...........jam........ (menyusun rencanan asuhan yang menyuluh)

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

LANGKAH VI : PELAKSANAAN tgl...........jam........ (pelaksanaan langsung asuhan efisien dan aman)

..........................................................................................................................................
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LANGKAH VII : EVALUASI tgl...........jam........(evaluasi hasil pelaksanaan)

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

PEMBIMBING AKADEMIK

( )

MAHASISWI PEMBIMBING

( ) ( )
NIM. NIP.
 ASUHAN KEBIDANAN PADA IBU NIFAS NORMAL
PADA NY…......... DI ............….

Pengkajian data dilakukan tanggal………….. pukul…………Wib

LANGKAH I : PENGKAJIAN DATA
DATA SUBYEKTIF
1. Biodata
Nama Ibu : ………… Nama Suami :….
Umur : ….....…thn Umur : ..……thn
Suku/bangsa : …......… Suku/Bangsa : .........
Agama : ……..... Agama : .........
Pendidikan : ……..... Pendidikan : …….
Pekerjaan : ……..... Pekerjaan : ……
Alamat Rumah : ……..... Alamat Kantor : ……
2. Keluhan utama : ......................................................................................................................
3. Riwayat Kesehatan
a. Riwayat kesehatan dahulu :.........................................................................................
b. Riwayat kesehatan sekarang :.........................................................................................
c. Riwayat kesehatan keluarga :.........................................................................................
4. Riwayat kehamilan, persalinan dan nifas yang lalu:
Thn Jenis Masalah/ anak
No Tempat Penolong
persalinan pesalinan gangguan JK BB/PB Ket
1
2
3
5. Riwayat persalinan sekarang
Tanggal bersalin : ………………… pukul : ……….
Jenis persalinan : …………………
Ditolong oleh : …………………………….. Tempat bersalin : ……………………
Lama persalinan
Ketuban pecah : ........... Jam ………. Menit
Secara : Spontan / Amniotomi Jumlah : ………. cc
Warna : ……………………… Bau : ……………………
Kala I : ........... Jam ………. Menit Komplikasi : ………………………
Kala II : ........... Jam ………. Menit Komplikasi : ………………………
Kala III : ........... Jam ………. Menit Komplikasi : ………………………
Kala IV : ........... Jam Komplikasi : ………………………
Plasenta : Lengkap / Sisa Plasenta
Cara pelepasan : Spontan / Manual Insersi :............................
Ukuran : ……………….. cm Berat : ………….. gram
Kelainan:……………………………………………………………………..
Perinium : ………………. Derajat laserasi : …………
Episiotomi : ………………….
Anastesi :…………………..
Hecting : ………………… Teknik hecting :………………………
Perdarahan
Kala I : ………… ml
Kala II : ………… ml
Kala III : ………… ml
Kala IV : ………… ml
 Tindakan lain
Pemberian Infus : ……………………………..
Tranfusi darah :......................... Golongan darah : ………………………
6. Keadaan bayi saat lahir
Jam Lahir : ……………… Nilai APGAR : …………………….
BB : ……………… gram PB : ………. Cm
Cacat bawaan :………………………. Anus: Ada/Tidak
Usia kehamilan : ……………… minggu
Komplikasi Kala I : ………………………………………………………………..
Komplikasi Kala II : …………………………………………………………………

7. Riwayat KB
NO Jenis Alkon Thn mulai Thn behenti Tempat & Alasan berhenti
penolong
1
2
3

8. Pola kebutuhan Sehari-hari

No Kegiatan Saat hamil Setelah melahirkan

1. Nutrisi
a. makan
frekuensi
Porsi
Jenis
keluhan
b. minum
frekuensi
Porsi
Jenis
keluhan
2. Eliminasi
a. BAK
Frekuensi
Konsistensi
Warna
Bau
keluhan
b. BAB
Frekuensi
Konsistensi
Warna
Bau
keluhan
3. Pola Istirahat
Tidur malam ......jam
Tidur siang .....jam
4. Pola Aktivitas
Didalam rumah
Di luar rumah
5. Personal hygiene
Mandi
Gosok gigi
Keramas
Ganti baju
6. Seksual
Frekuensi
Keluhan
9. Pola Psikososial Spiritual dan Budaya
Psikologi ibu post partum : ...................................................
Keadaan sosial : ...................................................
Keadaan budaya : ..................................................
Keadaan spiritual : ...................................................
DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum: BB sebelum hamil :.............kg
Kesadaran: BB selama hamil :.............kg
o
Tanda vital: TD.... .......mmHg, Suhu......... C, Nadi.........x/menit, Respirasi.........x/menit
2. Pemeriksaan status present
Kepala :…………………………………………………………………………………………
Rambut : …………………………………………………………………………………………
Muka : …………………………………………………………………………………………
Mata : …………………………………………………………………………………………
Hidung : …………………………………………………………………………………………
Mulut : …………………………………………………………………………………………
Telinga : …………………………………………………………………………………………
Leher : …………………………………………………………………………………………
Dada : …………………………………………………………………………………………
Payudara : …………………………………………………………………………………………
Abdomen : …………………………………………………………………………………………
Genitalia : …………………………………………………………………………………………
Anus : …………………………………………………………………………………………
Ekstermitas atas :…………………………………………………………………………………
Ekstermitas bawah :…………………………………………………………………………………
3. Pemeriksaan status obstetrik
TFU : ……………………………………………………………………
Kontraksi : ……………………………………………………………………
Lochea : ……………………………………………………………………
Jumlah perdarahan : ………………………………………………….
4. Pemeriksaan Laboratorim ( Jika ada Indikasi ).
Keton : …………………
Hb : …………………
Ht : …………………
Gol. Darah : …………………
Rhesus : …………………
Pemeriksaan Penunjang lainnya : …………………………………………………………..

LANGKAH II : INTERPRETASI DATA (Interpretasi data untuk mengidentifikasi diagnosa / masalah)

Diagnosa kebidanan:

Masalah :
Kebutuhan :

LANGKAH III : DIAGNOSA POTENSIAL ( diagnosa potensial dan cara mengatasi/ cara
Penanganannya)

LANGKAH IV : TINDAKAN SEGERA tgl...........jam........(menetapkan kebutuhan terhadap tindakan

segera)
LANGKAH V : PERENCANAAN tgl...........jam........ (menyusun rencanan asuhan yang menyuluh)
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

LANGKAH VI : PELAKSANAAN tgl...........jam........ (pelaksanaan langsung asuhan efisien dan aman)

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

LANGKAH VII : EVALUASI tgl...........jam........(evaluasi hasil pelaksanaan)

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

PEMBIMBING AKADEMIK

( )

MAHASISWI PEMBIMBING

( ) ( )
NIM. NIP.
 ASUHAN KEBIDANAN BAYI/BALITA SAKIT
PADA ……. DI ....................
Pengkajian Data
Dilakukan tgl ………………… pukul ……….. wib

I. PENGKAJIAN DATA
DATA SUBYEKTIF
1. Biodata anak
Nama :
Umur :
Tgl lahir :
Jenis kelamin :
2. Biodata Orang tua
Nama Ibu : Nama Suami :
Umur : Umur :
Suku/bangsa : Suku/Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat : Alamat :
3. Alasaan datang :
4. Riwayat Kehamilan
Anak ke ……
Umur kehamilan …… bulan
ANC ….. kali di ………….
Terapi yang diberikan pd ibu saat hamil …………………
Kebiasaan minum jamu/alkohol/obat-obatan ……………….
5. Riwayat persalinan
Melahirkan tgl :
Jenis persalinan :
Ditolong oleh :
BB/PB bayi :
APGAR Skore :
Reflek bayi :
Plasenta :
Komplikasi :
6. Riwayat kesehatan
Riwayat kesehatan anak :
Riwayat kesehatan keluarga :
7. Riwayat pemberian imunisasi:
Imunisasi 1 2 3 4
(tgl/bulan/th) (tgl/bulan/th) (tgl/bulan/th) (tgl/bulan/th)
Polio
BCG
Hepatitis
DPT
Campak
Hib

1
8. Pola kebutuhan sehari-hari
Keterangan
No Kegiatan
Sebelum Sakit Saat Sakit
1. Nutrisi
a. makan
Frekuensi
Porsi
Jenis
keluhan
b. minum
frekuensi
Porsi
Jenis
keluhan
2. Eliminasi
a. BAK
Frekuensi
Konsistensi
Warna
Bau
keluhan
b. BAB
Frekuensi
Konsistensi
Warna
Bau
keluhan
3. Pola Istirahat
Tidur malam
Tidur siang
4. Pola Aktivitas
Didalam rumah
Di luar rumah
5. Personal hygiene
Mandi
Gosok gigi
Keramas
Ganti baju
9. Psikososial spiritual
Pengambilan keputusan dalam keluarga: ……………………
Pola sosial : ……………….
10. Tumbuh kembang
Mengangkat kepala : …… bulan Telungkup : …… bulan
Duduk sendiri : …… bulan Merangkak : ……. bulan
Berjalan dituntun : ....... bulan Jalan sendiri : ....... bulan
Berbicara : ....... bulan Tidak mengompol : ....... bulan
Saat – saat gangguan pertumbuhan : …………..
Lain – lain : ……………..
DATA OBYEKTIF
1. Pemeriksaan umum
Tanda vital: Suhu ......oC Nadi ...... x/menit Respirasi ...... x/menit
BB/PB : ...... gram/ ...... cm
LK/LD/Lila : ...... cm/ ...... cm/ ...... cm
2. Pemeriksaan fisik
Kepala : …………………………………………………………………………………
Rambut : …………………………………………………………………………………
Muka : …………………………………………………………………………………
Mata : …………………………………………………………………………………
Hidung : …………………………………………………………………………………

2
 Mulut : …………………………………………………………………………………
Leher : …………………………………………………………………………………
Dada : …………………………………………………………………………………
Abdomen : …………………………………………………………………………………
Genitalia : …………………………………………………………………………………
Anus : …………………………………………………………………………………
Ekstermitas: …………………………………………………………………………………
II. INTERPRETASI DATA (Interpretasi data untuk mengidentifikasi diagnosa / masalah)
Diagnosa kebidanan :
Masalah :
Kebutuhan :

III. DIAGNOSA POTENSIAL

( diagnosa potensial dan cara mengatasi/ cara penanganannya)

IV. TINDAKAN SEGERA

(menetapkan kebutuhan terhadap tindakan segera)

V. PERENCANAAN (menyusun rencanan asuhan yang menyuluh)

1. …………………………………………………………………………………
2. …………………………………………………………………………………
3. …………………………………………………………………………………
4. …………………………………………………………………………………
5. …………………………………………………………………………………
6. …………………………………………………………………………………
7. …………………………………………………………………………………
VI. PELAKSANAAN (pelaksanaan langsung asuhan efisien dan aman)
1. …………………………………………………………………………………
…………………………………………………………………………………
2. …………………………………………………………………………………
…………………………………………………………………………………
3. …………………………………………………………………………………
…………………………………………………………………………………
4. …………………………………………………………………………………
…………………………………………………………………………………
5. …………………………………………………………………………………
…………………………………………………………………………………
6. …………………………………………………………………………………
…………………………………………………………………………………
7. …………………………………………………………………………………
8. EVALUASI (evaluasi hasil pelaksanaan)
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
PEMBIMBING AKADEMIK

( )
MAHASISWI PEMBIMBING

( ) ( )
NIM. NIP.

3
 ASUHAN KEBIDANAN BAYI/BALITA SEHAT
PADA ……. DI ....................
Pengkajian Data
Dilakukan tgl ………………… pukul ……….. wib

I. PENGKAJIAN DATA
DATA SUBYEKTIF
1. Biodata anak
Nama :
Umur :
Tgl lahir :
Jenis kelamin :
2. Biodata Orang tua
Nama Ibu : Nama Suami :
Umur : Umur :
Suku/bangsa : Suku/Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat : Alamat :
3. Alasaan datang :
4. Riwayat Kehamilan
Anak ke ……
Umur kehamilan …… bulan
ANC ….. kali di ………….
Terapi yang diberikan pd ibu saat hamil …………………
Kebiasaan minum jamu/alkohol/obat-obatan ……………….
5. Riwayat persalinan
Melahirkan tgl :
Jenis persalinan :
Ditolong oleh :
BB/PB bayi :
APGAR Skore :
Reflek bayi :
Plasenta :
Komplikasi :
6. Riwayat kesehatan
Riwayat kesehatan anak :
Riwayat kesehatan keluarga :
7. Riwayat pemberian imunisasi:
Imunisasi 1 2 3 4
(tgl/bulan/th) (tgl/bulan/th) (tgl/bulan/th) (tgl/bulan/th)
Polio
BCG
Hepatitis
DPT
Campak
Hib

1
8. Pola kebutuhan sehari-hari
No Kegiatan Keterangan
1. Nutrisi
a. makan
Frekuensi
Porsi
Jenis
keluhan
b. minum
frekuensi
Porsi
Jenis
keluhan
2. Eliminasi
a. BAK
Frekuensi
Konsistensi
Warna
Bau
keluhan
b. BAB
Frekuensi
Konsistensi
Warna
Bau
keluhan
3. Pola Istirahat
Tidur malam
Tidur siang
4. Pola Aktivitas
Didalam rumah
Di luar rumah
5. Personal hygiene
Mandi
Gosok gigi
Keramas
Ganti baju
9. Psikososial spiritual
Pengambilan keputusan dalam keluarga: ……………………
Pola sosial : ……………….
10. Tumbuh kembang
Mengangkat kepala : …… bulan Telungkup : …… bulan
Duduk sendiri : …… bulan Merangkak : ……. bulan
Berjalan dituntun : ....... bulan Jalan sendiri : ....... bulan
Berbicara : ....... bulan Tidak mengompol : ....... bulan
Saat – saat gangguan pertumbuhan : …………..
Lain – lain : ……………..
DATA OBYEKTIF
1. Pemeriksaan umum
Tanda vital: Suhu ......oC Nadi ...... x/menit Respirasi ...... x/menit
BB/PB : ...... gram/ ...... cm
LK/LD/Lila : ...... cm/ ...... cm/ ...... cm
2. Pemeriksaan fisik
Kepala : …………………………………………………………………………………
Rambut : …………………………………………………………………………………
Muka : …………………………………………………………………………………
Mata : …………………………………………………………………………………
Hidung : …………………………………………………………………………………
Mulut : …………………………………………………………………………………

2
 Leher : …………………………………………………………………………………
Dada : …………………………………………………………………………………
Abdomen : …………………………………………………………………………………
Genitalia : …………………………………………………………………………………
Anus : …………………………………………………………………………………
Ekstermitas: …………………………………………………………………………………
II. INTERPRETASI DATA (Interpretasi data untuk mengidentifikasi diagnosa / masalah)
Diagnosa kebidanan :
Masalah :
Kebutuhan :

III. DIAGNOSA POTENSIAL

( diagnosa potensial dan cara mengatasi/ cara penanganannya)

IV. TINDAKAN SEGERA

(menetapkan kebutuhan terhadap tindakan segera)

V. PERENCANAAN (menyusun rencanan asuhan yang menyuluh)

1. …………………………………………………………………………………
2. …………………………………………………………………………………
3. …………………………………………………………………………………
4. …………………………………………………………………………………
5. …………………………………………………………………………………
6. …………………………………………………………………………………
7. …………………………………………………………………………………
VI. PELAKSANAAN (pelaksanaan langsung asuhan efisien dan aman)
1. …………………………………………………………………………………
…………………………………………………………………………………
2. …………………………………………………………………………………
…………………………………………………………………………………
3. …………………………………………………………………………………
…………………………………………………………………………………
4. …………………………………………………………………………………
…………………………………………………………………………………
5. …………………………………………………………………………………
…………………………………………………………………………………
6. …………………………………………………………………………………
…………………………………………………………………………………
7. …………………………………………………………………………………
8. EVALUASI (evaluasi hasil pelaksanaan)
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
PEMBIMBING AKADEMIK

( )
MAHASISWI PEMBIMBING

( ) ( )
NIM. NIP.