FORMAT PENGKAJIAN ASUHAN KEBIDANAN

PADA IBU HAMIL

I. Pengkajian (Pengumpulan Data Dasar)

A. Identitas / Biodata

Nama Istri : ...................................... Nama suami : ......................................

Umur : ...................................... Umur : ......................................
Suku / Bangsa : ...................................... Suku / Bangsa : ......................................
Suku / Bangsa : ...................................... Suku / Bangsa : ......................................
Agama : ...................................... Agama : ......................................
Pendidikan : ...................................... Pendidikan : ......................................
Pekerjaan : ...................................... Pekerjaan : ......................................
Alamat : ...................................... Alamat : ......................................
No. Telp : ...................................... No. Telp : ......................................
Keluarga terdekat yang mudah dihubungi :………………………………………………………...

B. Anamnesa (Data Subjektif)

Pada tanggal : ........... Pukul : ......

1. Alasan kunjungan Pertama : ...... Rutin : ...... Ada Keluhan : ......

ini :..................................

....

Keluhan-keluhan :…………………………………………………………………………………….

2. Riwayat Menstruasi :

Menarche : Umur : ………..Tahun Lamanya : ………………...

Siklus : …..hari Dismenorrhoe : ………..

Banyaknya : ………………………..

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3. Riwayat kehamilan, persalinan dan nifas yang lalu
No Tgl Usia Jenis Tempat Komplikasi Bayi Nifas
Lahir Kehamilan Persalinan Persalinan
Penolong
Ibu Bayi PB/ BB/ Keadaan Lochea Laktasi
JK

4. Kontrasepsi yang pernah digunakan lama dan : .......................................................................

keluhannya
5. Riwayat kehamilan sekarang : .......................................................................
a. Hari pertama haid terakhir : .......................................................................
b. Keluhan-keluhan pad : .......................................................................
Trimester I : .......................................................................
Trimester II : .......................................................................
Trimester III : .......................................................................
c. Kapan pergerakan janin pertama kali : .......................................................................
dirasakan ibu
d. Pergerakan janin dalam 24 jam terakhir : .......................................................................
e. Keluhan-keluhan yang dirasakan ibu : .......................................................................
5L : .......................................................................
Mual dan muntah terus menerus : .......................................................................
Nyeri perut : .......................................................................
Demam tinggi : .......................................................................
Sakit kepala berat : .......................................................................
Penglihatan kabur : .......................................................................
Rasa nyeri/panas BAK : .......................................................................
Gatal pada vulva : .......................................................................
Pengeluaran pervaginam : .......................................................................
Nyeri & kemerahan pada tungkai : .......................................................................
Bengkak pada wajah, tangan & kaki : .......................................................................
f. Obat/suplemen termasuk jamu jamuan yang : .......................................................................
dikonsumsi

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g. Imunisasi
TT 1 TT 2 TT 3 TT 4 TT 5

Riwayat kesehatan ibu

h. Riwayat penyakit yang pernah diderita
Jantung : …………………….. Asma : ……………………..
Hipertensi : …………………….. TBC : ……………………..
Ginjal : …………………….. Epilepsi : ……………………..
DM : …………………….. PMS/IMS : ……………………..
Riwayat keturunan kembar : ……………………….
i. Riwayat alergi
Jenis makanan : ……………………..
Jenis obat-obatan : ……………………..
j. Riwayat transfusi darah : ……………………..
k. Riwayat operasi dinding rahim : ……………………..
l. Riwayat pernah mengalami : ……………………..
kelainan jiwa

6. Riwayat psikososial

a. Kehamilan ini : Direncanakan / tidak direncanakan

b. Respon ibu terhadap kehamilan ini : .......................................................................
c. Respon suami & keluarga terhadap : .......................................................................
kehamilan ibu
d. Hubungan dengan suami/keluarga : .......................................................................
e. Hubungan dengan tetangga & : .......................................................................
masyarakat
f. Kekhawatiran-kekhawatiran khusus : .......................................................................
7. Riwayat perkawinan : .......................................................................

Umur Saat Menikah : ........................ Tahun

Setelah Menikah Berapa Lama : ........................ Bulan/Tahun
Baru Hamil
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 8. Keadaan Ekonomi
Penghasilan per bulan : .......................................................................
Jumlah anggota keluarga yang : .......................................................................
ditanggung
9. Kebiasaan hidup sehari-hari
a. Personal hygiene
Mandi : .......................................................................
Sikat gigi : .......................................................................
Keramas : .......................................................................
Ganti pakaian dalam : .......................................................................

10. Pola makan dan

minum
Sebelum hamil Saat kehamilan sekarang
Pagi : ........................ Pagi : .......................
Siang : ....................... Siang : .......................
Malam : ....................... Malam : .......................
11. Pola eliminasi :
BAK BAB
Frek : ....................... Frek : .......................
Warna : ....................... Warna : .......................
Keluhan : ....................... Konsistensi : .......................
Keluhan : .......................
Masalah gangguan pencernaan :

Perubahan pola makan yang dialami pada kehamilan (termasuk ngidam, nafsu makan, dan lain-
lain) : ………………………………………………………………………………………………
……………………………………………………………………………………………………

12. Pola istirahat

a. Istirahat siang : .......................................................................
b. Istirahat malam : .......................................................................
13. Aktivitas sehari-hari
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 Beban kerja
Olah raga
Kegiatan spiritual
Hubungan seksual
Kebiasaan yang merugikan kesehatan
Kebiasaan merokok, minuman keras,
konsumsi obat-obatan terlarang
Budaya yang merugikan kesehatan
14. Persiapan untuk kegawatdaruratan
a. Pengambil keputusan
berhubungan dengan kesehatan
ibu
b. Tempat persalinan yang diinginkan
c. Petugas kesehatan yang diinginkan
oleh ibu untuk menolong persalinan
d. Persiapan donor darah
e. Persiapan biaya persalinan
f. Persiapan transportasi
g. Golongan darah
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
yang : .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................
: .......................................................................

C. PEMERIKSAAN FISIK (Data Objektif)

1. Pemeriksaan Umum
Kesadaran : Pernafasan : …………X/Menit

TD : …….. mmHg BB sebelum hamil : ...... Kg

Nadi : .........x/menit BB setelah hamil : ...... Kg
Suhu : ......°C TB : ...... cm
LiLA : ...... cm

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2. Pemeriksaan Khusus 3.

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a. Inspeksi
Kepala : …………………….
Rambut : …………………….
Mata : …………………….
Muka : …………………….
Mulut : …………………….
Gigi : …………………….
Leher : …………………….
Payudara : Simetris :
Areola mammae :
Papilla mammae :
Kolostrum/cairan lain :
Abdomen : Bekas luka operasi
Pembesaran perut
Striae
Linea alba
Genitalia : Kemerahan
: Pembengkakan
: Varices
: Oedema
Ekstremitas Atas : Ekstremitas Bawah :
Oedema : : Oedema :
Sianosis : : Varices :
Pergerakan : : Pergerakan :

b. Palpasi

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 Leopold I : ............................................................................................................

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Leopold II : ............................................................................................................

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Leopold III : ............................................................................................................

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Leopold IV : ............................................................................................................

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Mc. Donald : ......................................................

TBBJ : ......................................................
c. Auskultasi
DJJ : ......................................................
Frekuensi/irama : ......................................................
Intensitas : ......................................................
d. Perkusi
Reflek patella kanan : ......................................................
Reflek patella kiri : ......................................................

e. Pemeriksaan panggul luar

Distansia spinarum : ......................................................

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 Distansia cristarum : ......................................................
Conjugata eksterna : ......................................................
Lingkaran panggul : ......................................................
f. Pemeriksaan penunjang
Hb : ......................................................
Protein Urine : ......................................................
Glukosa Urine : ......................................................
USG : ......................................................
CTG : ......................................................

II. INTERPRETASI DATA DASAR

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III. IDENTIFIKASI DIAGNOSA DAN MASALAH POTENSIAL

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IV. MENGIDENTIFIKASI DAN MENETAPKAN KEBUTUHAN YANG MEMERLUKAN

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 PENANGANAN SEGERA

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V. MERENCANAKAN ASUHAN YANG MENYELURUH

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VI. IMPLEMENTASI (PELAKSANAAN)

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VII. EVALUASI

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 Medan,

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 Praktikan

………………………………..
NIM :

Mengetahui

Pembimbing Praktik Clinical Instrukture

…………………………………. ………………………………….
NIDN : NIP :

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