Salam Sehat dan Harmonis

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form askeb pada akseptor KB


ASUHAN KEBIDANAN
PADA Ny…. AKSEPTOR KB……….
DI……….

I.       SUBYEKTIF
      Pada tanggal :………………  oleh : …………….. pukul : …………………
1.      Identitas
Nama Ibu
Umur
Suku/bangsa
Agama
Pendidikan
Pekerjaan
Penghasilan
Alamat
No. telp.
No. register
:
:
:
:
:
:
:
:
:
:
Nama Suami
Umur
Suku/bangsa
Agama
Pendidikan
Pekerjaan
Penghasilan
Alamat
No. telp.

:
:
:
:
:
:
:
:
:

2.      Keluhan Utama (PQRST) :
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3.      Riwayat obstetri yang lalu
No
Kehamilan
Persalinan
BBL
     Nifas
UK
Peny.
Jenis
Pnlg.
Tmp
Peny
JK
PB/BB
Hdp/Mt
Usia
Kead.
Lak.





















































4.         Pola Kesehatan Fungsional
Pola Fungsi Kesehatan
Selama hamil
Setelah bersalin
1.Pola Nutrisi





2.Pola Eliminasi





3.Pola Istirahat





4.Pola Aktivitas





5.Pola seksual





6.   Pola persepsi dan pemeliharaan kesehatan  : merokok, alcohol, narkoba, obat – obatan, jamu, binatang peliharaan




5.      Riwayat penyakit sistemik yang pernah di derita :
1.      Jantung
2.      Ginjal
3.      Asma
4.      TBC
  1. Hepatitis
  2. DM
  3. Hipertensi
  4. TORCH
6.      Riwayat kesehatan dan penyakit keluarga
1.      Jantung
2.      Ginjal
3.      Asma
4.      TBC
5.      Hepatitis
6.      DM
7.      Hipertensi
8.      TORCH
9.      Gemeli
7.      Riwayat psikososiospiritual
·         Riwayat  emosional :
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·         Status perkawinan
Kawin             : …….. kali
Suami ke         : ……
Kawin I           : Umur ……………   tahun
                          Lamanya …………. tahun
Kawin ke II     : umur ……………   tahun
                          Lamanya…….......... tahun
·         Hubungan dengan keluarga
      Akrab              biasa                terganggu
·         Hubungan dengan orang lain
      Akrab              biasa                terganggu
·         Ibadah / spiritual
      Patuh               tidak patuh                            
·         Respon suami dan keluarga terhadap penggunaan KB:
.........................................................................................................................................
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·         Dukungan keluarga :
.........................................................................................................................................
·         Pengambil keputusan dalam keluarga :
..... ...................................................................................................................................
·         Tradisi :
..... ...................................................................................................................................
·         Riwayat KB :
..... ...................................................................................................................................
..... ...................................................................................................................................
..... ...................................................................................................................................

II.    OBYEKTIF
1.      Pemeriksaan Umum
a.    Keadaan umum         :
lemah                  baik
b.   Kesadaran
Compos mentis 
Apatis   
Somnolen
Sopor
Koma
c.    Keadaan emosional   :
kooperatif            depresi                      agresif             hipoaktif
bingung                menarik diri              cemas              marah
hiperaktif             gelisah
d.   Tanda –tanda vital
Tekanan darah : ……….. mmHg.
        berbaring               duduk                    berdiri
Nadi                : ……….. kali/menit
        teratur                  tidak teratur     
Pernafasan       : ………. Kali / menit
teratur               tidak teratur                 
dangkal             dalam                           
Suhu                :  …….. 0C
                 aksila            oral             rectal
2.   Antropometri
¨      BB periksa yang lalu            : …… . kg
¨      BB sekarang                         : …….. kg
¨      Tinggi Badan                       :……… cm
¨      Lingkar Lengan Atas           : …….. cm
3.      Pemeriksaan Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi)
a.       Wajah          : ....................................................................................................
      ..........................................................................................................................
      ..........................................................................................................................
      ..........................................................................................................................
b.      Rambut        : ...................................................................................................
      ..........................................................................................................................
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c.       Mata             : ...................................................................................................
      ..........................................................................................................................
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d.      Mulut & gigi : ..................................................................................................
      ..........................................................................................................................
      ..........................................................................................................................
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e.       Telinga         : ...................................................................................................
      ..........................................................................................................................
      ..........................................................................................................................
      ..........................................................................................................................
f.       Hidung         : ...................................................................................................
      ..........................................................................................................................
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g.      Dada            : ...................................................................................................
      ..........................................................................................................................
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h.      Mamae         : ...................................................................................................
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i.        Abdomen      :...................................................................................................
      ..........................................................................................................................
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j.        Genetalia     : ....................................................................................................  
      ..........................................................................................................................
      ..........................................................................................................................
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k.      Ekstremitas  : ...................................................................................................
      ..........................................................................................................................
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4.   Pemeriksaan Laboratorium
a.    Darah: ………………………………………………………………………..
..........................................................................................................................      
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b.   Urine : ……….............................................................................................
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5.   Pemeriksaan lain :
...............................................................................................................................
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III.    ASSESMENT
1.   Interpretasi Data Dasar
a.    Diagnosa    :   ..................................................................................................
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b.   Masalah      : ...................................................................................................
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c.    Kebutuhan  : ...................................................................................................
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2.   Antisipasi terhadap diagnosa/masalah potensial
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3.   Identifikasi kebutuhan akan tindakan segera/kolaborasi/rujukan
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IV.    PLANNING
Tujuan                  :………
Kriteria Hasil       : ………
                              ……….
1.   Intervensi
No.
Intervensi
Rasionalisasi



































2.   Implementasi
No
Hari/Tanggal/Jam
Implementasi
Paraf









































3.   Evaluasi : SOAP
No.
Hari/Tanggal/Jam
Evaluasi


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