ASUHAN KEBIDANAN PADA IBU HAMIL PATOLOGIS

PADA NY. ......... USIA ....... TAHUN G.. P.. A.. USIA HAMIL ...... MG
DENGAN ............................................
DI ..........................................................................

PENGKAJIAN
Tanggal : ............................... Jam : ...............................
Tempat : ...............................

IDENTITAS PASIEN
Identitas Pasien Suami
Nama :............................... Nama :...............................
Umur : ................................ Umur : ................................
Agama : .............................. Agama : ..............................
Pendidikan : .............................. Pendidikan : ..............................
Pekerjaan : ................................ Pekerjaan : ..............................
Suku bangsa: ......................... Suku bangsa : .........................
Alamat : .............................. Alamat : ..............................

I. DATA SUBYEKTIF

1. ALASAN DATANG :
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2. KELUHAN UTAMA :
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3. RIWAYAT KESEHATAN :
a. Riwayat kesehatan sekarang dan lalu :
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 b. Riwayat Penyakit Keluarga :
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4. RIWAYAT OBSTETRI
a. Riwayat Haid :
Menarche : …………………
Siklus :………………….
Warna : ………………..
Nyeri Haid: ………………..
Lama : ………………..
Leukorea : ………………..
Banyaknya :
hari ………, gantipembalut ….x/hari, ……. (penuh,1/2penuh,bercak2)
hari ………, gantipembalut ….x/hari, ……. (penuh,1/2penuh,bercak2)
hari ………, gantipembalut ….x/hari, ……. (penuh,1/2penuh,bercak2)
b. Riwayat Kehamilan Sekarang :
G ke ……, hamil …… mg
HPHT :…………………
HPL : …………………
GerakJanin : …………… sejak : ………… frek :…...
TT : ……………..x
Minumjamu/obatselainvitamin : …………….
ANC : …………….x
TM I : ANC ........... x
Tempat ANC : ................................................................
Keluhan / Masalah :...…………….....………………………………….....
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........................Supplement :
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PemberianFe :
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: …………………………………………………………......
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TM II : ANC ........... x
Tempat ANC : ................................................................
Keluhan / Masalah :...…………….....………………………………….....
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........................Supplement :
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PemberianFe :
……………………………………………………………...PenKes
: …………………………………………………………......
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TM III : ANC ........... x

Tempat ANC : ................................................................
Keluhan / Masalah :...…………….....………………………………….....
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........................Supplement :
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PemberianFe :
……………………………………………………………...PenKes
: …………………………………………………………......
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c. Riwayat Kehamilan persalinan dan nifas yang lalu :

5. RIWAYAT PERKAWINAN :
……..x sah/tdk lama pernikahan : …….
Usia ibu saat menikah : ……tahun Usia bapak saat menikah : ……tahun
Hubungan ibu & suami: ……………………..

6. RIWAYAT KB :
Alat KB yang pernah dipakai : …………………… Lamanya :……………….
Alasan Berhenti :…………………
Keluhan/masalah : ………………...................................
Rencana KB setelah bersalin : ……………….

7. POLA PEMENUHAN KEBUTUHAN SEHARI-HARI

a. Pola Nutrisi
Sebelum Hamil:
- Makan : frek :…….x/sehari
Komposisi : ……………………………………………………………………………
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- Minum :frek : ………gelas/hari, jenis : ……………………………………………...
- Keluhan :……………………………………………………………………………….

Selama Hamil :

- Makan : frek :…….x/sehari

Komposisi : ……………………………………………………………………………
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- Minum :frek : ………gelas/hari, jenis :……………………………………………….
- Keluhan :……………………………………………………………………………….

b. Pola Eliminasi
Sebelum Hamil :
- BAK :…x/hari, warna: ………………….., keluhan :……………..
- BAB :…x/hari, warna: ………………….., konsisitensi:…………., keluhan :……
Perubahan selama hamil :
- BAK : …x/hari, warna: ………………….., keluhan :……………..
- BAB : …x/hari, warna: ………………….., konsisitensi:………….., keluhan :……
 c. PolaAktivitas :
Sebelum Hamil :
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Keluhan :
Perubahan selama hamil :
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Keluhan :

d. Pola Istirahat dan tidur:

Sebelum Hamil :
- Tidur siang ……jam - tidur malam :…… jam keluhan : ……………
Perubahan selama hamil :
- Tidur siang ………jam - tidur malam :……… jam keluhan : ……………

e. Pola sexual:
Sebelum hamil : ………x/mgg, contact bleeding :……………keluhan:…………………
Selama hamil : ………x/mgg, contact bleeding :……….……keluhan:……………….

f. Pola hygiene :
Sebelum hamil : -mandi: ……x/hari, -gosok gigi: ……x/hari,
-ganti pakaian dalam :……x/hari, -ganti pakaian luar : ……x/hari
Selamahamil : -mandi: ……x/hari, -gosok gigi: ……x/hari,
-ganti pakaian dalam :……x/hari, -ganti pakaian luar : ……x/hari
Keluhan :……………………………………………………………………………….

g. Pola hidup sehat ( Sebelum dan selama hamil)

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8. DATA PSIKOSOSIAL DAN SPIRITUAL

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9. DATA PENGETAHUAN
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II. DATA OBYEKTIF
1. PEMERIKSAAN FISIK
a. Pemeriksaan umum
Keadaan umum : .............................. TD : .......................mmHg
Kesadaran : ............................. Nadi : ......................x/menit
BB sblm/slm : ......... kg / ...........kg Suhu : ..............oC
TB : .................. cm RR : .............. x/menit
LILA : .................... cm IMT : .....................
b. Status Present
Kepala : ……………………………………………………………………………........…
Mata : …………………………………………………………………………........……
Hidung :…………………………………………………………………………............…
Mulut : ………………………………………………………………………........………
Telinga :……………………………………………………………………………........…
Leher :……………………………………………………………………………........…
Ketiak :……………………………………………………………………………........…
Dada :……………………………………………………………………………........…
Perut :……………………………………………………………………………........…
Vulva :……………………………………………………………………………........…
Ekstremitas :
Atas :………………………………………………………………………………............
Bawah : ……………………………………………………………………………...........
Reflekpatella :…………………………………………………………………………….........
a. Status obstetric
1. Inspeksi :
Muka :……………………………………………………………………………………
Mamae :……………………………………………………………………………………
Abdomen :…………………………………………………………………………..
Vulva :……………………………………………………………………………………
2. Palpasi
Leopold I :………………………………………
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Leopold II :…………………………………………………………………………...
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Leopold III : …………………………………………………………………………..
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Leopold IV :…………………………………………………………………………...
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 TFU : ……………cm
TBJ :…………….gram
3. Auskultasi :
DJJ : + / - , frekuensi:……x/mnt, punctum max:………………………
Pemeriksaan Penunjang:………………………………………………………………….
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III. ASSESMENT
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IV. PELAKSANAAN
Tanggal : ………………………………… Jam: .............................................
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