Nama Mahasiswa : ...........................................

JURUSAN KEBIDANAN NIM : ...........................................

POLTEKKES PONTIANAK Tempat Praktik : ...........................................
Pembimbing : ...........................................
Tanggal : ...........................................

MANAJEMEN KEBIDANAN PADA GANGGUAN SISTEM

REPRODUKSI
Tanggal Kunjungan :
Nomor Register :
I. PENGKAJIAN
A. Data Subyektif
IDENTITAS
Klien Suami

Nama : ................................................................. ..................................................................

Umur : .................................................................
Agama : .................................................................
Suku/Bangsa : .................................................................
Pendidikan : .................................................................
Pekerjaan : .................................................................
Alamat rumah : .................................................................
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RIWAYAT KESEHATAN
1. Kunjungan saat ini
[ ] Kunjungan pertama
[ ] Kunjungan ulang
Keluhan Utama :
..............................................................................................................................
2. Riwayat Perkawinan
Kawin : ............................... kali
Kawin pertama umur : ............................... tahun
Dengan suami sekarang : ............................... tahun

3. Riwayat Menstruasi
Menarche : ............................... tahun
Siklus : Teratur / Tidak, ............................... hari
Lamanya : ............................... hari
Sifat Darah : Encer / Beku
Fluor Albus : Ya / Tidak
Dismenorhoe : Ya / Tidak
Masalah Lain :
..............................................................................................................................
Haid terakhir :
..............................................................................................................................
 4. Riwayat Kehamilan, persalinan dan nifas yang lalu

Kehamilan Persalinan Nifas

Hamil
Ke Tgl Umur Jenis Komplikasi Jenis BB
Penolong Laktasi Komplikasi
Lahir Kehamilan Persalinan Ibu Bayi Kelamin Lahir

5. Riwayat Kontrasepsi yang digunakan

6. Riwayat Kesehatan
a. Penyakit sistemik yang pernah/sedang diderita
…………………………………………………………………………………………
…………………………………………………………………………………………
b. Penyakit yang pernah/sedang diderita keluarga
…………………………………………………………………………………………
…………………………………………………………………………………………
c. Riwayat penyakit ginekologi
…………………………………………………………………………………………
…………………………………………………………………………………………
d. Riwayat penyakit sekarang
…………………………………………………………………………………………
…………………………………………………………………………………………

7. Pola Pemenuhan Kebutuhan sehari-hari

a. Pola nutrisi Makan Minum
Frekuensi ……………….. ………………..
Macam ……………….. ………………..
Jumlah ……………….. ………………..
Keluhan ……………….. ………………..

b. Pola eliminasi BAB BAK

Frekuensi ……………….. ………………..
Warna ……………….. ………………..
Bau ……………….. ………………..
Konsistensi ……………….. ………………..
Jumlah ……………….. ………………..

c. Pola aktivitas
Kegiatan sehari-hari : ……………………………………………………………………..
Istirahat / tidur : ……………………………………………………………………..

d. Seksualitas : Frekuensi
Keluhan : ……………………………………………………………………..

e. Personal Hygiene
Kebiasaan mandi ………….. kali/hari
Kebiasaan membersihkan alat kelamin : …………………………………………………….
Kebiasaan mengganti pakaian dalam : ………………………………………………………
 Jenis pakaian dalam yang digunakan : ……………………………………………………….

8. Keadaan Psiko Sosial Spiritual

a. Pengetahuan Ibu tentang gangguan/penyakit yang diderita saat ini
………………………………………………………………………………………………
………………………………………………………………………………………………
b. Pengetahuan Ibu tentang kesehatan reproduksi
………………………………………………………………………………………………
………………………………………………………………………………………………
c. Dukungan suami/keluarga
………………………………………………………………………………………………
………………………………………………………………………………………………

B. DATA OBJEKTIF
1. Pemeriksaan Fisik
a. Keadaan umum ………….. kesadaran ………………….
b. Tanda vital
Tekanan darah : ………………. mmHg
Nadi : ………………. Kali per menit
Pernafasan : ………………. Kali per menit
Suhu : ………………. 0C
c. TB : ……………….cm
BB : ……………….kg
d. Kepala dan leher
Hiperpigmentasi : …………………………………………………………………………..
Mata : …………………………………………………………………………..
Mulut : …………………………………………………………………………..
Leher : …………………………………………………………………………..
e. Payudara
Bentuk : …………………………………………………………………………..
Putting susu : …………………………………………………………………………..
Massa/tumor : …………………………………………………………………………..
f. Abdomen
Bentuk : ………………………………………………………………………….
Bekas luka : ………………………………………………………………………….
Massa/tumor : ………………………………………………………………………….
g. Ekstremitas
Edema : ………………………………………………………………………….
Varices : ………………………………………………………………………….
Reflek patela : ………………………………………………………………………….
h. Genetalia luar
Tanda chadwich : …………………………………………………………………………..
Varices : …………………………………………………………………………..
Bekas luka : …………………………………………………………………………..
Kelenjar bartholini : ………………………………………………………………………....
Pengeluaran : …………………………………………………………………………..
i. Anus hemoroid : ……………………………………………………………………….….

2. Pemeriksaan Dalam/Ginekologis
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
3. Pemeriksaan Penunjang
…………………………………………………………………………………………………
…………………………………………………………………………………………………
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II. ASASSMENT
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III. PENATALAKSANAAN

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Puskesmas /RS/RB : No. RM :
Nama Pasien :
Nama Bidan :
CATATAN PERKEMBANGAN
Tanggal & Jam Catatan Perkembangan (SOAP) Nama & Paraf
S:

O:

A:

P:

Pontianak, .................................................
Mahasiswa Pembimbing

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