Bidan Enggraini Purnama, STr.

Keb
Alamat : Jl. Sukamaju RT/RW.002/005 Kel. Padang Serai Kec. Kampung Melayu Kota
Bengkulu No. Telp : 0821-7579-1327

PENGKAJIAN AWAL KEBIDANAN

Tanggal : ....../......./........ Jam : ....... Jam Pemeriksaan : ...........

Diagnosa : .............................................
Tidak Diantar Datang Sendiri Diantar Keluarga Diantar perujuk
Umur :
Nama Pasien :
Alamat :
Pendidikan :
Agama :
Nama keluarga dan No. Telp yang bisa dihubungi : ........................ No. Telp : ...........................
1. Keluhan Utama :
2. Riwayat Keluhan : ..........................................................................................................................
............................................................................................................................
............................................................................................................................
3. Riwayat Menstruasi :
............... Umur ...............Thn Lamanya : ........... Disminorhoe
Spotting Menorhagia Methorhagia Pre Mens Syndrome
4. Riwayat Perkawinan Status : Belum Kawin Kawin Cerai
5. Riwayat Kehamilan, Persalinan, Nifas dan KB yang lalu
No Tgl UmurHamil Jenis Penolong Anak, BB Lahir Menyusui KB
Lahir Ab Prem Ater Persalinan Nak Non JK BB Hidup Me Ya Tid Alk La
ortu atur m es L P Nor Cac nin ak on ma
s mal at gga
l

1. Keadaan Umum : ..........................................................................................

2. Tanda-tanda Vital : TD : ...............mmHg Nadi : ...........x/i Pernapasan : .............x/i
 Suhu : ..............°C TB : ........... cm
3. Status Gizi : BB : ......... kg (Sebelum Hamil) BB : ..............kg (Sekarang) LILA : .........
4. Pemeriksaan Fisik
1) Mata : Konjungtiva : Pucat MerahMuda Sklera : Ikterik TidakIkterik
2) Dada dan Axila :
Mammae : Bentuk Simetris Asimetris PutingSusuMenonjol/Masuk Pengeluaran : Colustrum
3) Ekstremitas : Tungkai Simetris Asimetris Edema Reflex Patella
5. Pemeriksaan Khusus
1) Abdomen
a. INSPEKSI : ...................................................................................................................
...................................................................................................................
b. PALPASI :
TFU : ......... cm, Sympisis : ............; Pusat : ............; ProcesusXyfoideus : ............. ; Punggung : ............
Presentasi : ............... NyeriTekan LingkaranBandleBagianTerendah : ..........
Taksiran BB Janin : ................. gram
c. AUSKULTASI : DJJ : ...............x/menit Teratur Tidak Teratur
d. HIS/Kontraksi : ........................................................................................ (Tindis seperti di patograf)

6. Anamnesa
a. INSPEKSI
Pengeluaran Pervagina : Darah Lendir Air Ketuban Luka Jahitan Pisiotoms
b. INSPEKULOVAGINA : Dikerjakan Tdk Dikerjakan
7. Riwayat Hamil ini
HPHT : .........................
HPL : .........................
ANC : .............. x Dimana : ..............
Hamil Muda : Mual Muntah Pendarahan Lain-lain
Hamil Tua : Pusing Pendarahan Lain-lain
8. Riwayat Penyakit Masa Lalu/Operasi
Pernah dirawat : Tidak Ya, kapan : ............... Dimana :
Pernah dioperasi : Tidak Ya, kapan : ............... Jenis Operasi : ............. Dimana : ......
9. Riwayat Penyakit Keluarga ( Ayah, Ibu, Paman, Bibi ) : ( )
Hipertensi DM Jantung TBC Epilepsi Kelamin Bawaan Hamil
Kembar
Alergi Lain-lain : .......................
10. Riwayat Ginekologi
Infertilitas PMG Infeksi Virus Endometriosis Myoma Cervisitis Kronis
Kista Ovari Kanker PolipCerviks Operasi Kandungan Lain-lain
11. Pola Makan/Minum/Istirahat/Psikososial
Pola Makan : ........x/hari Pola Minum : ........cc/hari
Pola Eliminasi BAK : ........cc/hari, atau .......x/hari, warna : .......
BAB : ........x/hari, Karakteristik : ..................
 Pola Istirahat Tidur : ........ Jam/hari, Tidur terakhir jam ......... WITA Tanggal ............
Psikologi tentang Kehamilan/Persalinan/Nifas
................................................................................................................................................................................................
................................................................................................................................................................................................
..................
Dukungan sosial dari
: ......................................................................................................................................................
12. Pemeriksaan Vagina Toucher Bidan
................................................................................................................................................................................................
................................................................................................................................................................................................
..................
13. Pemeriksaan Penunjang
a. Darah : .......................................................
Urine : ..................................................................................
b. USG : .............................................................................................................................................
........
c. Lainnya : .............................................................................................................................................
........
ANALISA
DIAGNOSA :
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