Nama Anggota

Adinda Hesti Fitriani (PO.6224223261)

Bella Karissa Putri (PO.6224223267)
Rivani (PO.6224223306)
Wetha Arisca Anjelina (PO.6224223312)

FORMAT PENGKAJIAN PADA IBU AKSEPTOR KB

Hari / Tanggal :

Pukul :

Tempat Pengkajian :

Nomor Rekam Medik :

DATA SUBJEKTIF

A. IDENTITAS/BIODATA
Nama Ibu : Nama Suami :
Umur : Umur :
Suku/Bangsa : Suku/Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat Rumah : Alamat rumah :
Telepon : Telepon :

B. Alasan kunjungan & Keluhan

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C. Riwayat KB sekarang
Alat kontrasepsi yang digunakan :.............................................................................
Lama pemakaian :.............................................................................
Keluhan yang dirasakan :.............................................................................
D. Riwayat kesehatan
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E. Riwayat kesehatan keluarga

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F. Riwayat perkawinan
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G. Riwayat obstetri
1. Haid
Menarche : .......................................

Lamanya : .......................................
Siklusnya : .......................................

2. Riwayat kehamilan dan persalinan : G............ P........... A.........

H. Riwayat KB yang lain

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I. Data psikologis
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J. Pola kebiasaan sehari-hari 1. Pola nutrisi

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2. Pola eliminasi
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3. Pola tidur dan istirahat
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4. Pola personal hygiene
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5. Pola latihan dan aktivitas

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6. Pola seksualitas
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DATA OBJEKTIF

PEMERIKSAAN FISIK
1. Kesadaran umum
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2. Tanda-tanda Vital
Respirasi : .................x/menit Nadi x/menit

Tekanan darah : .................mmHg Suhu °C

3. BB sekarang :
TB : IMT :

4. Mamae
Ada benjolan :
5. Abdomen
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6. Genetalia
Inspeksi :

Inspekulo :

VT :

7. Ekstremitas atas dan bawah

Oedema : ..........................................
Varises : ..........................................

PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium
Tanggal : ............................................

Darah :

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Urine :

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2. Pemeriksaan penunjang lainnya Pap

Smear :
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USG/Rongent :

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Mamografi :

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Lain-lainya :

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ASSESMEN

Diagnosa :

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PLANNING

Tanggal : ....................................................... Jam : ...................................

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Palangka Raya,............................

Pembimbing lahan praktik Mahasiswa

( ........................................ ) (…………………………….)
NIP.......................................... NIM…………………………….

Mengetahui
Pembimbing Institusi

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