SEKOLAH TINGGI ILMU KESEHATAN

BINA SEHAT PPNI KABUPATEN MOJOKERTO

PRODI DIII KEBIDANAN
Jl. Raya Jabon KM.6 Mojokerto Telp.(0321)390203

FORMAT ASUHAN KEBIDANAN ANTENATAL CARE (ANC)

7 Langkah Varney

No. Reg : …………………….

Tgl & jam pengkajian : …………………….
Nama pengkaji : …………………….

IDENTITAS ISTRI SUAMI

Nama : ………………………………. ..........................................

Umur : ................................................. ..........................................
Suku : ................................................. ..........................................
Agama : ................................................. ..........................................
Pendidikan : ................................................. ..........................................
Pekerjaan : ................................................. ..........................................
Alamat : ................................................. ..........................................
................................................. ..........................................
................................................. ..........................................
No. Tlp : ................................................. ..........................................

1. PENGKAJIAN DATA
DATA SUBJEKTIF
1. Keluhan utama
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................

2. Riwayat Obstetri
Riwayat Kehamilan Sekarang : G.................P................A...............
HPHT : ............................................................................
Gerakan janin : ............................................................................
Keluhan saat hamil muda : ............................................................................

PNC : ............................................................................
............................................................................
Imunisasi TT : ............................................................................
Obat yang dikonsumsi : Obat (................................................................)
Jamu (................................................................)
3. Riwayat Haid
Menarche : …………………………………………
 Siklus : …………………………………………
Lamanya : …………………………………………
Banyaknya : …………………………………………
Desmenorhoe : …………………………………………

4. Riwayat Kehamilan, nifas dan persalinan yang lalu

Hamil Tgl Usia Jenis Penolong Penyulit Anak Nifas

Ke Partus Kehamilan partus kehamilan & J BB PB AS Penyulit
Persalianan K I

5. Riwayat Ginekologi
Infertilitas : ....................................................................................................
Masa : ....................................................................................................
Penyakit : ....................................................................................................
Operasi : ....................................................................................................

6. Riwayat KB
Kontrasepsi yang dipakai : ............................................................................
Keluhan : ……………………………………………........
Kontrasepsi yang lalu : …………………………………………............
Lamanya pemakaian : ……………………………………………........
Alasan berhenti : ............................................................................

7. Riwayat Penyakit lainnya : …………………………………………………

…………………………………………………
............................................................................
8. Pola Nutrisi : Makan : .....X/hari (teratur /tidak teratur)
Pantang makan : ................................................
Minum : .............................................................

9. Pola Eliminasi : BAB : ..............X/hari

BAK : .............X/hari
Masalah : ............................................................................

10. Pola Tidur : Malam : ..................Jam

Siang : ..................Jam
Masalah : …………………………………………………

11. Data sosial

Dukungan Suami :……………………………………..…………...
Dukungan keluarga : ............................................................................
Masalah : …………………………………………………
DATA OBJEKTIF

1. Kesadaran
(__) Komposmentis
(__) Somnolent
(__) Sopor
(__) Sopor komatus
(__) Komatus

2. Tanda-tanda Vital
Nadi ……………X/mnt
Suhu …………...X/mnt
Tensi …………..mmHg
Respirasi ……….X/mnt

3. Kepala
Rambut : …………………………………………………………………
Mata : Konjungtiva : …………………………………………………
Sclera : …………………………………………………
Pengelihatan : …………………………………………………
Telinga : …………………………………………………………………
Hidung : …………………………………………………………………
…………………………………………………………………
Mulut : …………………………………………………………………
Leher : …………………………………………………………………
…………………………………………………………………
…………………………………………………………………

4. Thorax
Dada : Bentuk simetri : Ya (__) Tidak (__)
Mamae : Bentuk simetris : Ya (__) Tidak (__)
Puting Susu : ………………………………………....
Benjolan : …………………………………………
Ekskresi : …………………………………………
Paru-paru : …………………………………………………………………
Jantung : …………………………………………………………………
5. Abdomen
Inspeksi : Bentuk : …………………………………………………
Striae : ……………………………………....................
Bekas luka Operasi : ………………………………..................
Palpasi : Tinggi Fundus Uteri : ………… …Cm
Lingkar Perut : .................... Cm
Posisi Janin : Leopold I : ……………………………………...
Leopold II : ……………………………………..
Leopold III :…………………………………….
Leopold IV : ……………………………………
Kontraksi Uterus : frekuensi :……………………………….
Interval : ……………………………...
Intensitas : ……………………………
Auskultasi DJJ : .............................................................................................
 6. Genetalia Luar
Bentuk : …………………………………………………………………
Varices : …………………………………………………………………
Oedema : …………………………………………………………………
Massa / Kista : ....................................................................................................
Pengeluaran pervigam : .......................................................................................

7. Ekstremitas (tangan & kaki)

Bentuk : Kaki : ................................. Tangan : .......................................
Kuku : Kaki : ................................ Tangan : .......................................
Refleks Patela : ................................
Oedema : ................................

8. Kulit
Warna : ....................................
Turgor : ....................................

9. Data Penunjang (LABORATORIUM)

a. Pemeriksaan urine
Protein : .........................................
Reduksi : .........................................
b. Pemeriksaan darah
Hb : .............................
Golongan darah : .............................
c. Pemeriksaan lain-lain bila diperlukan
.....................................................................................................................
\
Kesimpulan: ( 9 Ikhtisar) ................................................................................................
.....................................................................................................................

2. ANALISA / DIAGNOSA MASALAH

Data Subyektif : ....................................................................................................
Data Obyektif :.....................................................................................................
Diagnosa :.....................................................................................................
Masalah :.....................................................................................................
Kebutuhan :.....................................................................................................

3. ANTISIPASI DIAGNOSA/MASALAH POTENSIAL

4. IDENTIFASI KEBUTUHAN SEGERA

5. PERENCANAAN
DX :
TUJUAN
- Jangka Pendek:
- Jangka Panjang:
KRITERIA HASIL:
INTERVENSI:
1 ..................................................................................................................................
R/
 2 ..................................................................................................................................
R/
3 ..................................................................................................................................
R/

6. PENATALAKSANAAN
DX :
Tanggal :
Jam :
1 ..................................................................................................................................

2 ..................................................................................................................................

3 ..................................................................................................................................

7. EVALUASI
DX :
Tanggal :
Jam :
S ..................................................................................................................................

O..................................................................................................................................

A..................................................................................................................................

P ..................................................................................................................................