BIDAN TIKA WIDYASARI, AM.

Keb
POLINDES DESA CISAAT
Jalan K.H. Zaenal Arifin No.129 RT.002 RW.005 Desa Cisaat
Kecamatan Waled – Kabupaten Cirebon – Jawa Barat
0231 – 8666818 085324484300 | 087829026874

PENGKAJIAN ASUHAN KEBIDANAN DAN PERSALINAN NORMAL

NOMOR REKAM MEDIS [RM] ........................................................................
IDENTITAS / BIODATA :
Nama : ................................................... Nama Suami : ...................................................
Suku Bangsa : ................................................... Suku Bangsa : ...................................................
Umur : ............. tahun Umur : ............. tahun
Agama : ................................................... Agama : ...................................................
Pendidikan : ................................................... Pendidikan : ...................................................
Pekerjaan : ................................................... Pekerjaan : ...................................................
Alamat : ................................................... Alamat : ...................................................
Telepon/HP : ................................................... Telepon/HP : ...................................................
Tanggal Masuk Jam
A DATA SUBYEKTIF
1 Keluhan Utama :
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2 Riwayat Perkawinan :
Kawin ………. kali, lama menikah ………. tahun
3 Riwayat Kehamilan, Persalinan dan Nifas :
G ………. P ………. A ……….
HPHT : ...........................................................................
TP : ............................................................................
Keadaan
Tanggal Tempat Usia Jenis Penolong
No Penyulit BB Anak
Partus Partus Kehamilan Persalinan Persalinan
Sekarang
1
2
3
4
4 Riwayat Hamil Sekarang :
Hamil Muda : ( ) Mual ( ) Muntah ( ) Pendarahan ( ) Lainnya : ...........................................
Hamil Tua : ( ) Mual ( ) Muntah ( ) Pendarahan ( ) Lainnya : ...........................................
5 Riwayat Penyakit yang lalu / Operasi :
Pernah dirawat : ( ) Kapan : ....................... Dimana : ..........................................................
Pernah dioperasi : ( ) Kapan : ........................ Dimana : ..........................................................
6 Riwayat Penyakit Keluarga (Ayah & Ibu) yang pernah menderita pernah diderita :
 ( ) Kanker ( ) Penyakit Hati ( ) Hipertensi ( ) Diabetes Melitus [DM]
( ) Penyakit Ginjal ( ) Malaria ( ) PMS ( ) Kelainan Bawaan
( ) Hamil Kembar ( ) TBC ( ) Epilepsi ( ) Alergi
( ) Jantung ( ) Asthma ( ) Lainnya : ...................................................................
7 Riwayat Gynekologi :
( ) Interfilitas ( ) Infeksi Virus ( ) Servisitis Cronis ( ) Endometritir
( ) Myoma ( ) Polip Servix ( ) Kanker Kandungan ( ) Operasi Kandungan
( ) Lainnya : ...............................................................
8 Riwayat Keluarga Berencana [KB] :
Metode KB terakhir : ......................................................... Lama : .................................................
Komplikasi dari KB : ( ) Pendarahan ( ) Polip Servix ( ) PID/Radang Panggul
( ) Lainnya : ...............................................................
B DATA OBJEKTIF :
PEMERIKSAAN FISIK :
1 Pemeriksaan Umum :
Keadaan Umum : ........................................ Kesadaran : ..................................................
Berat Badan : ................. kg Tinggi Badan : ................. cm
Tekanan Darah : ................. mmHg Nadi : ................. kali/menit
0
Suhu : ................. C Pernafasan : ................ kali/menit
2 Keadaan Fisik :
Mata : ( ) Pandangan Mata Kabur ( ) Berkunang-kunang
( ) Sekret ( ) Conjungtivitis
( ) Sklera : Pucat / Tidak Pucat
Dada & Axyla : ( ) Mammae Simetris ( ) Areola Hyperpigmentasi
( ) Putting Susu Menonjol ( ) Tumor
( ) Pengeluaran Kolostrum ( ) Nyeri Tekan
( ) Tanda Dimpling ( ) Retraksi
3 Pemeriksaan Khusus :
a. Obstetrik :
Abdomen
Inspeksi :
( ) Membesar dengan Arah Memanjang ( ) Melebar
( ) Pelebaran Vena ( ) Linea Alba
( ) Linea Ligra ( ) Striae Lividae
( ) Striae Albican ( ) Luka Bekas Operasi
( ) Lainnya : ............................................................
Palpasi :
TFU : ................. cm Letak Punggung : ( ) puka / ( ) puki
Bagian Terendah : ................................ Taksiran Berat Janin : .................... gram
Auskultasi :
DJJ : .................... kali/menit ( ) Teratur ( ) Tidak Teratur
Penurunan Kepala : .................... / 5
HIS/Kontraksi : ........................................ ( ) Teratur ( ) Tidak Teratur
b. Gynekologi :
Genital
Inspeksi Pengeluaran per Vaginam : ( ) Darah ( ) Lendir ( )Air Ketuban
Inspeksi Anus : ( ) Haemoroid
 Pemeriksaan Dalam :
Vulva/Vagina : .................................................................
Portio : .................................................................
Presentasi : .................................................................
Hodge : .................................................................
UUK : .................................................................
Malage : .................................................................
4 Ekstrimitas Atas Bawah : ( ) Tungkai Simetris/Asimetris ( ) Edema ( ) Reflex
5 Pemeriksaan Khusus dan Nifas :
Payudara :
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Abdomen :
Palpasi TFU : ................. cm Kontraksi Uterus : ...........................................................................
Pengeluaran Darah per Vaginam : .................... CC Lochea : ..........................................................
Perineum : ..........................................................................................................................................
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6 Pemeriksaan Penunjang :
Laboratorium :
Darah (Hb) : ................. gr %
Urine : .................
D ANALISA :
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E PENATALAKSANAAN :
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