ASUHAN KEBIDANAN PADA IBU HAMIL
No RM :.....................
Masuk tgl/jam :.....................
1. Identitas Istri Suami
Nama :...................... .........................
Umur :...................... ..........................
Agama :...................... ..........................
Pendidikan :...................... ..........................
Pekerjaan :...................... ...........................
Suku/bangsa :..................... ...........................
Alamat :....................... ...........................
Telp :........................ ...........................
3 Anamnesa
a. Keluhan utama
.............................................................................................................................
b. Riwayat perkawinan
Perkawinan ke..................menikah sejak umur..........................................................
Lama perkawinan.......................................................................................................
c. Riwayat haid
Menarche.....................HPM......................................................................................
HPL..................................................lama..................................................................
Teratur/tidak..................................................sakit/tidak............................................
Siklus..........................................................................................................................
d. Riwayat Obstetri
G.............P............A.............
no
|
Th
|
Jenis persalinan
|
penolong
|
tempat
|
H/M
|
Jenis
|
BB lahir
|
Komplikasi
|
Ket
|
e . Riwayat KB
No
|
PASANG
|
LEPAS
| ||||||||
metode
|
tgl
|
petugas
|
tempat
|
Ket
|
tgl
|
petugas
|
tempat
|
alasan
|
ket
| |
f. Riwayat Kesehatan
a) Riwayat Kesehatan Yang Lalu
b) Riwayat Kesehatan Sekarang
c) Riwayat Kesehatan Keluarga : riwayat persalinan
Kembar baik dari keluarga ibu maupun suami
g. Riwayat Kesehatan Sekarang
ANC di....................sejak umur kehamilan.....................................................................
Gerakan pertama kali dirasakan pada umur kehamilan....................................................
Gerakan janin selama 2 jam.............................................................................................
Frekuensi periksa TM I..............TM II..........................TM III......................................
Senam hamil.....................................................................................................................
Riwayat Imunisasi TT Catin :..........................................................................................
Imunisasi TT : pernah / tidak :.........................................................................................
Imunisasi TT 1 tgl ..........................................TT 11 tgl..................................................
Pendidikan Kesehatan yang diperoleh :
Trimester
|
Materi pendidikan kesehatan
|
I
| |
II
| |
III
|
Permasalahan dan Keluhan dalam kehamilan
Trimester
|
Masalah/keluhan
|
Tindakan/terapi
|
I
| ||
II
| ||
III
|
h. Pola Kebutuhan Sehari-hari
a) Nutrisi
Pola makan sehari-hari :........................................................................................
Jenis :........................................................................................
Makanan pantangan :........................................................................................
Pola minum :.........................................................................................
Masalah :.........................................................................................
b) Eliminasi
a. BAK
Frekuensi............................Jumlah..............................warna...............................
Keluhan.................................................................................................................
b. BAB
Frekuensi................................jumlah.....................................warna.....................
Keluhan.................................................................................................................
c. Istirahat
Siang............................................Malam........................................................
Keluhan...........................................................................................................
d. Aktifitas :.........................................................................................
e. Personal higiene :.........................................................................................
f. Pola seksual :........................................................................................
i. Data Psikososial Spiritual
Tanggapan ibu dan keluarga
Terhadap kehamilan :.................................................................................
Pengetahuan ibu dan keluarga
Tentang kehamilan :....................................................................................
Pengmbilan keputusan oleh :............................................................
Ketaatan ibu beribadah :.................................................................
Ibu tinggal bersama :.................................................................
Hewan piaraan :.................................................................
Rencana melahirkan di :...............................................................
B. Data objektif
1. Pemeriksaan Umum
KU :.........................................................................................
Kesadaran :.........................................................................................
TB :.........................................................................................
BB : Sebelum hamil :............................................................
Kunjumgan yang lalu :....................................................
Sekarang :.........................................................................................
Lila :.........................................................................................
Vital sign : T:.................N:..................S:.....................R:...............
2.Pemeriksaan fisik
Kepala :........................................................................................
Muka :.........................................................................................
Mulut :........................................................................................
Gigi :.........................................................................................
Mata :.........................................................................................
Telinga :.........................................................................................
Hidung :.........................................................................................
Leher :.........................................................................................
Aksila :........................................................................................
Dada :.........................................................................................
Payudarah :.........................................................................................
3.Pemeriksaan Obstetri
Abdomen : TFU :............................................................................. LI :.............................................................................
LII :.............................................................................
LIII :.............................................................................
LIV :.............................................................................
TBBJ :.............................................................................
D JJ :.........................................................................
Puktum maksimu
Pemeriksaan panggul luar : terutama primi gravida ( bila ada indikasi)
Genetalia : Inspeksi /inspekulo (bila da indikasi)
Ekstremitas :Oedema, refleksi, varises (kanan/kiri)
4.Pemeriksaan penunjang
a. USG : tgl ............../hasil...................................................................................
ib. Lab :
a) Urine : tgl..............................(PP test, Protein,Glukosa dll)
b) Darah :tgl................................(Hb, Al, HMT, Golongan dara )
II Interpreasi data
A. Diagnosa Kebidanan :
· Untk ibu hamil usia rreproduksi sehat :
Contoh : Seorang ibu primigravida usia reproduksi sehat
· Untuk ibu hamil usia reproduksi tidak sehat (umur <20 th/>35th):
Contoh : Seorang ibu primigravida usia reproduksi tidak sehat hamil..............minggu..............hrari keadaan ibu dan janin normal dengan faktor resiko.
Data dasar : DS : Ibu mengatakan................................................................
D O : VS, LILA, palpasi Leopod, DJJ, Px penunjang
B. Masalah
Data-data
yang ditemukan diluar diagnosa kebidanan dan berhubungan dengan
ketidaknyamanan pasien(eks : cemas,KTD, makanan pantangan dan penyakit
diluar kebidanan , dan lain-lain)
Data dasar : DS/DO
III. DIAGNOSA POTENSIAL
Untuk hamil normal atau tidak ada
Potensial : keadaan yang harus dilkukan segera.
IV. ANTISIPASI MASALAH / TINDAKAN SEGERA
Untuk hamil normal tidak ada
V. PERENCANAAN
Tanggal /jam
VI. PELAKSANAAN
Tanggal/jam
VII. EVALUASI
Tanggal/jam
CATATAN PERKEMBANGAN
Tanggal.........................................................................Jam.......................................
DATA SUBJEKTIF
.........................................................................................................................................................................................................................................................................................................................................................................................................
DATA OBJEKTIF
.........................................................................................................................................................................................................................................................................................................................................................................................................
ASSESMENT
.........................................................................................................................................................................................................................................................................................................................................................................................................PLANNING
........................................................................................................................................................................................................................................................................................................................................................................................................
