ASUHAN KEBIDANAN KESEHATAN REPRODUKSI

No. Medrec :..................................

Tgl Masuk :..................................
Tgl & Jam Pengkajian :..................................
Tempat Pengkajian :..................................
Nama Pengkaji :..................................

A. DATA
SUBJEKTIF
IDENTITAS
ISTRI SUAMI
Nama : ................................................... ......................................................
Umur : ................................................... ......................................................
Suku : ................................................... ......................................................
Agama : ................................................... ......................................................
Pendidikan : ................................................... ......................................................
Pekerjaan : ................................................... ......................................................
Alamat : ................................................... ......................................................
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No.Telepon : ................................................... ......................................................

1. Alasan datang
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2. Keluhan Utama
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3. Riwayat Obstetri yang lalu

3.1 Riwayat Haid
3.1.1 Menarche : ............................................................................
3.1.2 Siklus : ............................................................................
3.1.3 Lamanya : ............................................................................
3.1.4 Banyaknya : ............................................................................
3.1.5 Dismenorhoe : ............................................................................
3.1.6 Gejala Premenstrual : ............................................................................
3.1.7 Tanggal Menstruasi : ............................................................................
3.1.8 Menopause : ............................................................................
3.2 Riwayat kehamilan, nifas dan persalinan yang lalu
Hamil Tgl Usia Jenis Penolon Penyulit Anak Nifas
Ke Partu Kehamila Partus g Kehamilan JK BB PB ASI Penyulit
s n &
Persalinan

4. Riwayat Ginekologi
4.1 Infertilitas : ....................................................................................................
4.2 Massa : ....................................................................................................
4.3 Penyakit : ....................................................................................................
4.4 Operasi : ....................................................................................................

5. Riwayat KB
5.1 Riwayat Penggunaan Kontrasepsi : ................................................................
5.2 Jenis Kontrasepsi : ................................................................
 5.3 Jangka Waktu : ................................................................
5.4 Efek Samping / Keluhan : ................................................................
5.5 Alasan berhenti : ................................................................

6. Riwayat Perkawinan
6.1 Kawin/Tidak : ....................................................
6.2 Usia waktu kawin : ....................................................
6.3 Status Perkawinan : ....................................................
6.4 Banyaknya perkawinan/jumlah pasangan : ....................................................
6.5 Lamanya Perkawinan : ....................................................
6.6 Pola Hubungan ....................................................

7. Riwayat Penyakit Dahulu dan Sekrang

7.1 Penyakit yang pernah dialami : ................................................
7.2 Lamanya pengobatan : ................................................
7.3 Obat yang pernah dan sedang dikonsumsi : ................................................
7.4 Alergi (obat/makanan) : ................................................
7.5 Riwayat penyakit keluarga yang pernah dialami : ...............................................

8. Pola Aktivitas Sehari-hari

8.1 Pola nutrisi
Makan : ............................................................................
Pantangan makan : ............................................................................
Minum : ............................................................................
8.2 Pola eliminasi
BAB : ............................................................................
BAK : ............................................................................
8.3 Personal Hygiene
Frekuensi mandi : ............................................................................
Frekuensi ganti pakaian : ............................................................................
8.4 Gaya Hidup
Olah raga : ............................................................................
Istirahat : ............................................................................

9. Riwayat Sosial dan Psikologis

9.1 Psikologis
Respon klien mengatasi masalah : ................................................................
Masalah psikologi klien : ................................................................
Hubungan klien dengan orang lain : ................................................................
Dukungan suami : ................................................................
Dukungan keluarga : ................................................................
Pengambil keputusan dalam keluarga : ................................................................
Perubahan/masalah seksual : ................................................................
Lingkungan sosial klien : ................................................................
9.2 Sosial Budaya
Hubungan dengan suami : ................................................................
Hubungan dengan keluarga : ................................................................
Hubungan dengan tetangga : ................................................................
Pantangan-pantangan : ................................................................

B. DATA OBJEKTIF
1. Pemeriksaan Fisik
a. Tanda-tanda vital
Nadi..........................................x/mnt
Suhu......................................... 0C
Tensi.........................................mmHg
Respirasi...................................x/mnt

b. Berat badan................................kg
Tinggi badan..............................cm
 c. Mata
Konjungtiva : ....................................................................................................
Sklera : ....................................................................................................

d. Leher
Kelenjar tiroid : ....................................................................................................
Vena jugularis : ....................................................................................................

e. Payudara
Bentuk : ........................................................................................
Konsistensi : ........................................................................................
Pembesaran : ........................................................................................
Benjolan/massa : ........................................................................................
Hygiene payudara : ........................................................................................

f. Abdomen
Pembesaran : ........................................................................................
Bentuk parut : ........................................................................................
Striae : ........................................................................................
Jaringan parut : ........................................................................................
Benjolan/massa : ........................................................................................

g. Ekstremitas
Warna kuku : ........................................................................................
Oedema : ........................................................................................
Varises : ........................................................................................
Refleks patella : ........................................................................................

Pemeriksaan dibawah ini dilakukan jika hanya atas indikasi

1. Pemeriksaan Genitalia Eksterna
Vulva
a. Oedema : ........................................................................................
b. Varises : ........................................................................................
c. Perlukaan : ........................................................................................
d. Pengeluaran cairan : ........................................................................................
e. Jumlah : ........................................................................................
2. Pemeriksaan Pelvis

Inspeksi (menggunakan spekulum)

a. Warna serviks : ........................................................................................
b. Erosi : ........................................................................................
c. Nodul : ........................................................................................
d. Massa : ........................................................................................
e. Cairan/sekret : ........................................................................................
f. Perdarahan : ........................................................................................
g. Lesi/luka : ........................................................................................

Pemeriksaan Dalam
a. Lokasi portio : ........................................................................................
b. Konsistensi : ........................................................................................
c. Dilatasi : ........................................................................................
d. Nyeri goyang : ........................................................................................
e. Massa : ........................................................................................

DATA PENUNJANG
1. Pemeriksaan Lab : ....................................................................................................
2. USG : ....................................................................................................
3. Rontgen : ....................................................................................................
4. Tes-tes lain : ....................................................................................................
C. ANALISA
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D. PENATALAKSANAAN
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Bidko Pelaksana Asuhan

Titin Sumartini, Amd.Keb Elis Liswati, Amd.keb

NIP.197503252003122003 NIP.198312122017042001

Mengetahui Kepala UPTD

Puskesmas Kabandungan

H. SUPRAPTO, SKM

NIP. 196706241990031008