ASUHAN KEBIDANAN PADA IBU
BERSALIN
Ny................................................DI……….................................
I.
SUBYEKTIF
Pada tanggal
:……………… oleh : …………….. pukul : …………………
No register :
1.
Identitas
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Nama Ibu
Umur
Suku/bangsa
Agama
Pendidikan
Pekerjaan
Penghasilan
Alamat
No. telp.
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Nama Suami
Umur
Suku/bangsa
Agama
Pendidikan
Pekerjaan
Penghasilan
Alamat
No. telp
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2.
Keluhan utama (PQRST) :
·
Tanda – tanda bersalin :
Kontraksi sejak tanggal…………….. pukul :………….
Frekwensi …………..
Lamanya……………. Kekuatan ………….
·
Pengeluaran pervaginam
...................................................................................................................................
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...................................................................................................................................
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3.
Riwayat obstetrik yang lalu
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Suami ke
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Kehamilan
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Persalinan
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BBL
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Nifas
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hamil ke
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Peny.
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Jenis
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Pnlg
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Tmpt
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Peny
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JK
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PB/BB
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Hdp/Mt
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usia
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Kead.
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Lak
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4.
Riwayat kehamilan sekarang
- Keluhan :
Trimester I :...............................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Trimester II :.............................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Trimester
III :..............................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
- Pergerakan anak pertama kali : ………… bulan
- Frekwensi pergerakan dalam 3 jam
terakhir : ………… kali
- Penyuluhan yang sudah di dapat : ………...
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- Imunisasi yang sudah di dapat :
…………
5.
Pola Fungsi Kesehatan
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Pola Fungsi Kesehatan
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Sebelum hamil
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Selama hamil
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1.Pola
Nutrisi
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2.Pola
Eliminasi
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3.Pola
Istirahat
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4.Pola
Aktivitas
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5.Pola
seksual
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6.
Pola persepsi dan pemeliharaan kesehatan : merokok, alcohol,
narkoba, obat – obatan, jamu, binatang peliharaan
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6.
Riwayat penyakit sistemik yang
pernah di derita :
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1.
Jantung
2.
Ginjal
3.
Asma
4.
TBC
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7.
Riwayat kesehatan dan penyakit
keluarga
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1.
Jantung
2.
Ginjal
3.
Asma
4.
TBC
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5.
Hepatitis
6.
DM
7.
Hipertensi
8.
TORCH
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9.
Gemeli
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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 : ....................................................................................................
.............................................................................................................................
................................................................................................................................
................................................................................................................................
b.
Rambut : ...................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
c.
Mata : ......................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
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 :
……….............................................................................................
..........................................................................................................................
..........................................................................................................................
5.
Pemeriksaan lain :
·
USG :
………………………………………………………………………...
..........................................................................................................................
..........................................................................................................................
·
NST :
…………………………………………………………………………
..........................................................................................................................
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III. ASSESMENT
1.
Interpretasi Data Dasar
Diagnosa : .............................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Masalah : .............................................................................................................
...................................................................................................................................
...................................................................................................................................
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
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No.
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Intervensi
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Rasionalisasi
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2. Implementasi
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No.
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Hari/Tanggal/Jam
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Implementasi
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Paraf
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Lembar observasi
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No.
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Hari/tanggal/jam
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TTV
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His
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DJJ
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Ket ( vt , urine , bandl ,
input )
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3. Evaluasi : SOAP
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No.
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Hari/Tanggal/Jam
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Evaluasi
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S :
O :
A : G…P… UK… kala I
Aktif
P : Kala I
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KALA II
Tujuan : ….
Kriteria :
- Implementasi
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No.
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Hari/Tanggal/Jam
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Implementasi
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Paraf
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- Evaluasi
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No.
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Hari/Tanggal/Jam
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Evaluasi
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S :
O :
A : P… kala III
P : Kala III
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KALA III
Tujuan :………
Kriteria Hasil………
- Implementasi
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No.
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Hari/Tanggal/Jam
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Implementasi
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Paraf
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- Evaluasi
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No.
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Hari/Tanggal/Jam
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Evaluasi
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S :
O :
A : P… kala IV
P : Kala IV
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KALA IV
Tujuan :………
Kriteria Hasil………
- Implementasi
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No.
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Hari/Tanggal/Jam
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Implementasi
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Paraf
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- Evaluasi
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No.
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Hari/Tanggal/Jam
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Evaluasi
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S :
O :
A :
P :
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Di blog ini juga Saya membagikan beberapa hasil karya tulis Saya seperti yang bisa sobat baca secara gratis. Harapan Saya yaitu semoga blog ini dapat memberikan kontribusi yang bermanfaat bagi sobat semua.
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