ASUHAN KEBIDANAN
PADA Ny…. G….P……UK….. FISIOLOGIS
DI……….
I.
SUBYEKTIF
Tanggal
………………. Oleh ………………….. Pukul : ……………..
1. Identitas
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Nama Ibu
Umur
Suku/bangsa
Agama
Pendidikan
Pekerjaan
Penghasilan
Alamat
No. telp.
No. register
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Nama Suami
Umur
Suku/bangsa
Agama
Pendidikan
Pekerjaan
Penghasilan
Alamat
No. telp.
No. register
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:
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2. Keluhan utama
(PQRST) :
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
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...................................................................................................................................
3. Riwayat Kebidanan :
·
Kunjungan : pertama/ulang ke .....
·
Riwayat menstruasi :
·
Menarce : ……………. tahun
·
Siklus : …………..hari
teratur tidak teratur
·
Banyaknya : ……….. cc
·
Lamanya : ……….. hari
·
Sifat darah : cair bergumpal flek
Sifat darah : cair bergumpal flek
·
Warna : merah tua merah segar
Warna : merah tua merah segar 
Merah kehitaman coklat
·
Bau : anyir busuk
Bau : anyir busuk
·
Disminorhoe : ya tidak
Disminorhoe : ya tidak
§ Lama :
………… hari
·
Flour albus : ya tidak
Flour albus : ya tidak
§ Kapan : ………..(sebelum/sesudah
haid)
§ Lama : ……… hari
§ Bau : …..
§ Warna : …..
§ Banyak :……..
·
HPHT :………..
4. Riwayat obstetri 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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5. Riwayat kehamilan sekarang
1.
Keluhan :
Trimester I :.............................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
Trimester II :.............................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
Trimester III :.............................................................
........... .............................................................................................................................
........... .............................................................................................................................
........... .............................................................................................................................
2.
Pergerakan anak pertama kali : ………… bulan
3. Frekwensi pergerakan dalam 3 jam terakhir : ………… kali
4. Penyuluhan yang sudah di dapat : ………...
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a.
Nutrisi
b.
Imunisasi
c.
Istirahat
d.
Kebersihan
diri
e.
Aktifitas
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f.
Tanda-tanda
bahaya kehamilan
g.
Perawatan
payudara/laktasi
h.
Seksualitas
i.
Persiapan
persalinan
j.
KB
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5. Imunisasi yang sudah di dapat : …………
6.
Pola Kesehatan
Fungsional
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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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7.
Riwayat penyakit sistemik yang pernah di
derita :
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1.
Jantung
2.
Ginjal
3.
Asma
4.
TBC
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8.
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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9.
Riwayat psiko-social-spiritual
·
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
a. Kehamilan ini
Direncanakan Tidak direncanakan
b. Hubungan dengan keluarga
akrab biasa terganggu
c. Hubungan dengan orang lain
akrab biasa terganggu
d. Ibadah / spiritual
patuh tidak patuh
e. Respon ibu dan keluarga terhadap kehamilannya :
........... ...............................................................................................................................
........... ...............................................................................................................................
...............................................................................................................................
f. Dukungan keluarga :
........... ...............................................................................................................................
...............................................................................................................................
g. Pengambil keputusan dalam
keluarga :
...............................................................................................................................
h.
Tempat dan petugas yang diinginkan untuk
bersalin :
...............................................................................................................................
i. Tradisi :
...............................................................................................................................
j. 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
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 : ..................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
e.
Telinga : ......................................................................................................
........... ..........................................................................................................................
........... ..........................................................................................................................
........... ..........................................................................................................................
f.
Hidung : ......................................................................................................
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............................................................................................................................
g.Dada : ......................................................................................................
........... ..........................................................................................................................
........... ..........................................................................................................................
........... ..........................................................................................................................
h.Mamae : ......................................................................................................
........... ..........................................................................................................................
........... ..........................................................................................................................
........... ..........................................................................................................................
........... .........................................................................................................................
i.
Abdomen :......................................................................................................
...........................................................................................................................
¨
Leopold I : ………………………………………………...............
............................................................................................................................
.......................................................................................................................
¨
Leopold II :…………………………………………………………
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
¨
Leopold III :………………………………………………………….
........... .......................................................................................................................
........... .......................................................................................................................
.......................................................................................................................
¨
Leopold IV :…………………………………………………………
...................................................................................................................................
...................................................................................................................................
.......................................................................................................................
¨
TFU Mc. Donald : …….. cm
¨
TBJ/EFW :
…….. gram
¨
DJJ : ………..
j.
Genetalia : .......................................................................................................
........... ..........................................................................................................................
........... ..........................................................................................................................
........... ..........................................................................................................................
k.Ekstremitas : ......................................................................................................
........... ..........................................................................................................................
......................................................................................................................................
......................................................................................................................................
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 :
k.
USG : ………………………………………………………………………...
........... ..........................................................................................................................
..........................................................................................................................
l.
NST :
…………………………………………………………………………
........... ..........................................................................................................................
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III. ASSESMENT
1. Interpretasi Data Dasar
a.
Diagnosa : ..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
b.
Masalah : ...................................................................................................
..................................................................................................
..................................................................................................
c.
Kebutuhan : ...................................................................................................
...........
........... ..................................................................................................
........... ..................................................................................................
........... .................................................................................................
........... ..................................................................................................
........... ..................................................................................................
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2. Antisipasi terhadap
diagnosa/masalah potensial
........... ...............................................................................................................................
........... ...............................................................................................................................
........... ...............................................................................................................................
........... ...............................................................................................................................
........... ...............................................................................................................................
........... ...............................................................................................................................
3. Identifikasi kebutuhan
akan tindakan segera/kolaborasi/rujukan
........... .............................................................................................................................
........... .............................................................................................................................
........... .............................................................................................................................
........... .............................................................................................................................
........... .............................................................................................................................
........... .............................................................................................................................
........... .............................................................................................................................
........... .............................................................................................................................
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IV. PLANNING
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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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 :
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O: ……………………………………………….
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A:
……………………………………………….
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P :
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