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

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

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

MANAJEMEN KEBIDANAN PEMERIKSAAN SADARI DAN ATAU IVA

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
Keluhan Utama : ..............................................................................................................................

2. 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 : ..............................................................................................................................

3. 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

4. Riwayat Kontrasepsi yang digunakan : ……………………………………………………………..

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

…………………………………………………………………………………………………
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B. DATA OBJEKTIF
1. Pemeriksaan Fisik
a. Keadaan umum ………….. kesadara ………………….
b. Tanda vital
Tekanan darah : ………………. mmHg
Nadi : ………………. Kali per menit
Pernafasan : ………………. Kali per menit
Suhu : ………………. 0C

c. Payudara
Bentuk : …………………………………………………………………………….
Putting susu : …………………………………………………………………………….
Massa/tumor : …………………………………………………………………………….
d. Genetalia luar
Tanda chadwich : …………………………………………………………………………….
Varices : …………………………………………………………………………….
Bekas luka : …………………………………………………………………………….
Kelenjar bartholini : …………………………………………………………………………..
Pengeluaran : …………………………………………………………………………….
e. Anus hemoroid : …………………………………………………………………………….

2. Pemeriksaan Penunjang
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II. ASSESMENT
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III. PENATALAKSANAAN

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

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