Salam Sehat dan Harmonis

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FORM ASKEB PADA IBU BERSALIN


ASUHAN  KEBIDANAN   PADA  IBU  BERSALIN
Ny................................................DI……….................................

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

:
:
:
:
:
:
:
:
:
Nama Suami
Umur
Suku/bangsa
Agama
Pendidikan
Pekerjaan
Penghasilan
Alamat
No. telp

:
:
:
:
:
:
:
:
:
2.      Keluhan  utama (PQRST)             :
·         Tanda – tanda bersalin :
Kontraksi sejak tanggal…………….. pukul :………….
Frekwensi …………..
Lamanya……………. Kekuatan ………….
·         Pengeluaran pervaginam
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
3.   Riwayat obstetrik yang lalu  
Suami ke
Kehamilan
Persalinan
BBL
Nifas
hamil ke
UK
Peny.
Jenis
Pnlg
Tmpt
Peny
   JK
PB/BB
Hdp/Mt
usia  
   Kead.
       Lak






















































































4.   Riwayat kehamilan sekarang
  • Keluhan                       :
      Trimester I                  :...............................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
             Trimester II                 :.............................................................................................
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...................................................................................................................................
...................................................................................................................................
Trimester III                :..............................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
  • Pergerakan anak pertama kali                         : ………… bulan
  • Frekwensi pergerakan dalam 3 jam terakhir   : ………… kali
  • Penyuluhan yang sudah di dapat                                : ………...
  • Nutrisi
  • Imunisasi
  • Istirahat
  • Kebersihan diri
  • Aktifitas
  • Tanda-tanda bahaya kehamilan
  • Perawatan payudara/laktasi
  • Seksualitas
  • Persiapan persalinan
  • KB
  • Imunisasi yang sudah di dapat           : …………
5.   Pola  Fungsi Kesehatan
Pola Fungsi Kesehatan
Sebelum hamil
Selama hamil
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




6.   Riwayat penyakit sistemik yang pernah di derita :
1.      Jantung
2.      Ginjal
3.      Asma
4.      TBC
  1. Hepatitis
  2. DM
  3. Hipertensi
  4. TORCH
7.   Riwayat kesehatan dan penyakit keluarga
1.      Jantung
2.      Ginjal
3.      Asma
4.      TBC
5.      Hepatitis
6.      DM
7.      Hipertensi
8.      TORCH
9.      Gemeli

8.   Riwayat psikososiospiritual
·         Riwayat  emosional :
Trimester I      :       ....................................................................................................
...................................................................................................................................
Trimester II     : .........................................................................................................
...................................................................................................................................
Trimester III    : .........................................................................................................
...................................................................................................................................
·         Status perkawinan
Kawin : …….. kali
Suami ke         : ……
Kawin I           : Umur ……………   tahun
                     Lamanya ………….      tahun
Kawin ke II : umur ……………   tahun
  Lamanya…….......... tahun
·         Kehamilan ini
      Direncanakan                Tidak direncanakan
·         Hubungan dengan keluarga
      akrab               biasa                terganggu
·         Hubungan dengan orang lain
      akrab               biasa                terganggu
·         Ibadah / spiritual
       patuh              tidak patuh                   
·         Respon ibu dan keluarga terhadap kehamilannya :
.........................................................................................................................................
.........................................................................................................................................
.....
·         Dukungan keluarga :
.........................................................................................................................................
.....
·         Pengambil keputusan dalam keluarga :
..... ...................................................................................................................................
·         Tempat dan petugas yang diinginkan untuk bersalin :    
..... ...................................................................................................................................
·         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
a.       Tekanan darah  : ……….. mmHg.
 berbaring                      duduk              berdiri
b.      Nadi                  : ……….. kali/menit
 teratur                          tidak teratur     
c.       Pernafasan                    : ………. Kali / menit
 teratur              tidak teratur                 
 dangkal            dalam                           
d.      Suhu                 :  …….. 0C
 aksila                oral                  rectal
e.       Antropometri
¨      BB sebelum Hamil       : …….. kg
¨      BB periksa yang lalu    : …… . kg
¨      BB sekarang                 : …….. kg
¨      Tinggi Badan                :……… cm
¨      Lingkar Lengan Atas    : …….. cm
f.       Taksiran persalinan             : …………………………………
g.      Usia Kehamilan                  : ………………..minggu
2.      Pemeriksaan Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi)
a.       Wajah          : ....................................................................................................
   .............................................................................................................................
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................................................................................................................................
b.      Rambut        : ...................................................................................................
..........................................................................................................................      
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..........................................................................................................................      
c. Mata             : ......................................................................................................
..........................................................................................................................      
..........................................................................................................................      
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d.      Mulut & gigi : ..................................................................................................
      ..........................................................................................................................
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e. Telinga         : ......................................................................................................
..........................................................................................................................      
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f. Hidung         : ......................................................................................................
  ..........................................................................................................................      
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g.Dada            : ......................................................................................................
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h.Mamae         : ......................................................................................................
..........................................................................................................................      
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i.  Abdomen      :......................................................................................................
  ..............................................................................................................
¨   Leopold I              : ………………………………………………...............
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.......................................................................................................................
¨   Leopold II             :…………………………………………………………
.......................................................................................................................
.......................................................................................................................      
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¨   Leopold III           :………………………………………………………….
.......................................................................................................................      
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¨   Leopold IV            :…………………………………………………………
.......................................................................................................................      
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¨   TFU Mc. Donald : …….. cm
¨   TBJ/EFW              :  …….. gram
¨   DJJ                        : ………..
j.  Genetalia     : .......................................................................................................  
..........................................................................................................................      
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k.Ekstremitas  : ......................................................................................................
..........................................................................................................................      
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3.   Pemeriksaan Panggul
a.    Distancia Spinarum  : …………….cm
b.   Distancia cristarum  : …………….cm
c.    Conjugata eksterna  : …………….cm
d.   Lingkar panggul       : …………….cm
e.    Distancia tuberum    : …………….cm

4.   Pemeriksaan Laboratorium
a.    Darah: ………………………………………………………………………...
..........................................................................................................................      
..........................................................................................................................
b.   Urine : ……….............................................................................................
..........................................................................................................................      
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5.   Pemeriksaan lain :
·      USG : ………………………………………………………………………...
..........................................................................................................................      
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·      NST : …………………………………………………………………………
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III.    ASSESMENT
1.      Interpretasi Data Dasar
Diagnosa    : .............................................................................................................      
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 Masalah      : .............................................................................................................
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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
     KALA I
    Tujuan :………
     Kriteria Hasil………
1.      Intervensi
No.
Intervensi
Rasionalisasi



































2.      Implementasi
No.
Hari/Tanggal/Jam
Implementasi
Paraf








































Lembar observasi
No.
Hari/tanggal/jam
TTV
His
DJJ
Ket ( vt , urine , bandl , input  )









































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




































S :





O :





A : G…P… UK… kala I  Aktif




P : Kala I


KALA II
Tujuan : ….
Kriteria :
  1. Implementasi
No.
  Hari/Tanggal/Jam
Implementasi
Paraf






































  1. Evaluasi
No.
Hari/Tanggal/Jam
Evaluasi




S :










O :









A : P… kala III




P : Kala III










KALA III
Tujuan :………
Kriteria Hasil………
  1. Implementasi
No.
Hari/Tanggal/Jam
Implementasi
Paraf






































  1. Evaluasi
No.
Hari/Tanggal/Jam
Evaluasi


S :










O :











A : P… kala IV

P : Kala IV











KALA IV
Tujuan :………
Kriteria Hasil………
  1. Implementasi
No.
Hari/Tanggal/Jam
Implementasi
      Paraf






































  1. Evaluasi
No.
Hari/Tanggal/Jam
Evaluasi


S :








O :









A :









P :







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