Sispac Unikal

ASUHAN KEBIDANAN NIFAS

PADA NY                   DENGAN                            

DI                                 TAHUN                   

Tanggal           :

Waktu             :

Tempat            :

I.            PENGUMPULAN DATA

A.    DATA SUBJEKTIF

1.      Biodata

Nama (Istri)       :                                   Nama (Suami) :                      

Umur                 :                                   Umur               :                        

Agama               :                                   Agama             :                        

Pendidikan        :                                   Pendidikan      :                        

Pekerjaan           :                                   Pekerjaan         :                        

Suku bangsa      :                                   Suku bangsa    :                        

Alamat               :                                                                                  

Tanggal masuk/jam        :                                                                      

No. RM                         :                                                                        

2.      Alasan datang

                                                                                                                                                                                                                                                                                                                                            

3.      Keluhan utama

                                                                                                                                                                                                                                                                                                                                            

4.      Riwayat obstetric dan ginekologi

a.       Riwayat kehamilan, persalinan dan nifas yang lalu

Anak ke	Umur kehamilan	Jenis persalinan			Penolong persalinan	Nifas	JK	Kead. anak
		Spt	Tind	op				Hidup		Meninggal
								Umur	BBL	Umur	sebab

b.      Riwayat kehamilan sekarang

G         P         A                  

ANC               : TM I           :            kali

 TM II         :            kali

 TM III        :            kali

Imunisasi TT 1 :                     Tanggal :                  

  TT 2 :                    Tanggal :                  

Keluhan TM I         :                                                                                   Terapi yang diberikan         :                                              

        Nasehat yang diberikan          :                                              

Keluhan TM II        :                                                                      

        Terapi yang diberikan             :                                              

        Nasehat yang diberikan          :                                              

Keluhan TM III      :                                                                      

        Terapi yang diberikan             :                                              

        Nasehat yang diberikan          :                                              

5.      Riwayat persalinan sakarang

a.       Waktu persalinan     :                                                                      

b.      Jenis persalinan        :                                                                      

c.       Penyulit persalinan  :                                                                      

d.      Ketuban pecah jam  :                                                                      

e.       Bayi lahir jam          :            WIB   Warna  :            Bau     :          

Berat lahir                :            gram

Jenis kelamin           :                      

Cacat                       :                      

6.      Riwayat kesehatan

a.       Penyakit yang pernaah diderita

·         Penyakit infeksi  :                                                          

·         Penyakit keturunan         :                                                          

·         Kecelakaan/trauma          :                                                          

·         Riwayat operasi  :                                                          

·         Penyakit organ                :                                                          

b.      Kesehatan ibu sekarang

·         Penyakit infeksi  :                                                          

·         Penyakit keturunan         :                                                          

·         Penyakit organ                :                                                          

c.       Riwayat kesehatan keluarga

·         Penyakit infeksi  :                                                          

·         Penyakit keturunan         :                                                          

·         Penyakit organ                :                                                          

·         Riwayat gamelly :                                                          

7.      Kebiasaan

·         Pantangan makan                   :                                                          

·         Minuman jamu                       :                                                          

·         Obat-obatan                           :                                                          

·         Miras/Rokok              :                                                          

·         Memelihara binatang  :                                                          

8.      Riwayat Obstetric

a.       Riwayat Haid

·         Menarche          :                                   Flaur Albus     :          

·         Siklus/Teratur    :                                               -Warna            :          

·         Lama/Jumlah     :                                               -Bau    :          

·         Dysmenorhea    :                                               -Lama  :          

-Gatal  :          

b.      Riwayat penggunaan kontrasepsi

·         Jenis kontrasepsi             :                                              

·         Lama                                           :                                              

·         Keluhan                                       :                                              

·         Alasan lepas                                :                                              

·         Rencana yang akan datang         :                                              

·         Alasan                                         :                                              

9.      Kebutuhan sehari-hari (Sekarang           WIB)

a.       Pola nutrisi

·         Makan (x/hari)                                                                         

Porsi                                                                                         

Gangguan                                                                                

·         Minum (x/hari)                                                                         

Jenis                                                                                         

Gangguan                                                                                

b.      Pola eliminasi

·         BAB                                                                                        

Warna                                                                                      

Konsistensi                                                                              

Gangguan                                                                                

·         BAK                                                                                        

Warna                                                                                      

Gangguan                                                                                

c.       Pola istirahat

·         Siang                                                                                        

·         Malam                                                                                      

·         Gangguan                                                                                

d.      Pola aktivitas                                                                                  

e.       Pola personal hygiene

·         Mandi                                                                                      

·         Keramas                                                                                   

·         Gosok gigi                                                                               

·         Ganti baju                                                                                

f.       Pola seksual

·         Frekuensi                                                                                 

·         Gangguan                                                                                

10.  Data psikologis

·         Tanggapan ibu ataskehamilannya    :                                              

·         Tanggapan suami dan keluarga        :                                              

·         Kesiapan mental ibu                        :                                              

11.  Data sosial ekonomi

·         Penghasilan                                      :                                              

·         Tangguang jawab perekonomian     :                                              

·         Pengambil keputusan                       :                                              

12.  Data perkawinan

·         Perkawinan ke                                 :                                              

·         Lama perkawinan                            :                                              

13.  Data spiritual

                                                                                                                                                                                                                                                                                                                                            

14.  Data sosial budaya

                                                                                                                                                                                                                                                                                                                                            

15.  Data pengetahuan ibu

                                                                                                                                                                                                                                                                                                                                            

B.     DATA OBYEKTIF

1.      Pemeriksaan Fisik

a.       Kesadaran                :                                                                      

b.      Keadaan umum        :                                                                      

c.       Tanda-tanda vital     : TD                 :                        mmHg

  Nadi              :                        x/menit

 Suhu               :                        °C

 Respirasi         :                        x/menit

d.      Tinggi badan            :                                    cm

e.       Berat badan             :                                    kg

f.       LILA                       :                                    cm

g.      Status present

·         Kepala-Muka

Ø  Kepala                        :                                                                                                                                                                                                                                                         

Ø  Rambut                      :                                                          

                                                                                                                                               

Ø  Muka                          :                                                          

                                                                                                                                               

Ø  Mata                           :                                                          

Konjungtiva           :                                                          

Sklera                     :                                                          

Ø  Hidung                  :                                                          

                                                                                                                       

Ø  Mulut/bibir             :                                                          

                                                                                                                       

Ø  Telinga                   :                                                          

                                                                                                                       

·         Leher                                :                                                          

                                                                                                                       

·         Aksila                               :                                                          

                                                                                                                       

·         Dada                                :                                                          

Ø  Bentuk                       :                                                          

Ø  Mamae                       :                                                          

·         Abdomen                                    :                                                          

                                                                                                                       

·         Ekstrimitas                      :                                                          

                                                                                                                       

·         Genetalia                         :                                                          

                                                                                                                       

·         Anus                                :                                                          

                                                                                                                       

2.      Pemeriksaan Obstetri

a.       Isnpeksi

·         Muka                          :                                                          

                                                                                                                       

·         Mamae                        :                                                          

Ø  Puting susu          :                                                          

Ø  Kolostrum/ASI    :                                                          

Ø  Kebersihan          :                                                          

·         Abdomen                   :                                                          

                                                           

Ø  Luka bekas operasi:                                                          

Ø  TFU                       :                                                          

Ø  Kontraksi               :                                                          

·         Genetalia                    :                                                          

                                                           

Ø  Vulva/vagina         :                                                          

Ø  Luka perineum       :                                                          

Ø  PPV                       :                                                          

Ø  Kateterisasi            :                                                          

b.      Perkusi

·         Reflek patella ka/ki    :                                                          

·         CVAT                                    :                                                          

3.      Pemeriksaan penunjang

·         Pemeriksaan laboratorium

                                                                                                                                                                                                                                                                                                                                                                                                                                      

·         Pemeriksaan rontgen

                                                                                                                                                                                                                                                                                                                                                                                                                                      

·         USG

                                                                                                                                                                                                                                                                                                                                                                                                                                      

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       

                                                                                                                       

                                                                                                                       

                                                                                                                       

                                                                                                                       

                                                                                                                       

                                                                                                                                   

ASUHAN KEBIDANAN BAYI BARU LAHIR (BBL)

PADA BAYI NY                   DENGAN                            

DI                                 TAHUN                   

Tanggal           :

Waktu             :

Tempat            :

I.   PENGUMPULAN DATA

A.    DATA SUBJEKTIF

1.      Biodata

Nama bayi             :                                  

Tanggal lahir          :                                  

Umur bayi             :                                  

Jenis kelamin         :                                  

Nama (Istri)           :                                   Nama (Suami) :                      

Umur                     :                                   Umur               :                        

Agama                   :                                   Agama             :                        

Pendidikan                        :                                   Pendidikan      :                        

Pekerjaan               :                                   Pekerjaan         :                        

Suku bangsa          :                                   Suku bangsa    :                        

Alamat                   :                                                                                  

Tanggal masuk/jam:                                                                                  

No. RM                 :                        

2.      Alasan datang

                                                                                                                                                                                                                                                                                                                                                     

3.      Riwayat kesehatan keluarga

a.       Penyakit kelainan darah          :                                                          

                                                           

b.      Kelainan kongenital                :                                                                                                                                                                                  

c.       Penyakit infeksi                       :                                                          

                                                           

d.      Penyakit keturunan                 :                                                                                                                                                                                  

e.       Penyakit organik                     :                                                                                                                                                                                  

f.       Riwayat gamelly                     :                                                                                                                                                                                  

4.      Riwayat kehamilan

a.       G         P          A        

b.      Usia kehamilan            :             minggu

c.       Imunisasi TT 1 :                        Tanggal                     

     TT 2            :                        Tanggal                     

5.      Kebutuhan sehari-hari pada bayi baru lahir

a.       Pola nutrisi

·         Minum                                                                                          

Jenis                                                                                              

Gangguan                                                                                     

b.      Pola eliminasi

·         BAB (x/hari)                                                                                

Jam                                                                                               

Warna                                                                                           

Konsistensi                                                                                   

Gangguan                                                                                     

·         BAK                                                                                             

Jam                                                                                               

Warna                                                                                           

Gangguan                                                                                     

c.       Pola personal hygiene

·         Mandi                                                                                           

·         Ganti popok                                                                                 

·         Ganti baju                                                                                     

B.     DATA OBYEKTIF

1.      Catatan proses persalinan

a.       Waktu persalinan (Tgl&Jam)                :                                              

b.      Jenis persalinan                         :                                              

c.       Penolong persalinan                             :                                              

d.      Penyulit saat persalinan                        :                                              

e.       Obat-obatan yang dipakai selama        : Kala I                        :                      

 Kala II           :                      

f.       Lama persalinan Kala I                        :                                              

 Kala II                      :                                              

g.      Ketuban pecah jam                               :                                              

Warna                                                   :                                              

Bau                                                       :                                              

h.      Tindakan segera setelah lahir

·    Mengeringkan bayi                           :                                              

·    Perawatan & pemotongan tali pusat :                                              

·    IMD                                                  :                                              

·    Resusitasi bayi                                  :                                              

·    Menghangatkan bayi                         :                                              

i.        Nilai APGAR

	1’	5’	10’
A = Appearance
P = Pulse
G = Grimace
A = Activity
R = Respiration
Jumlah

2.      Pemeriksaan fisik

a.       Keadaan umum                        :

b.      Tanda-tanda vital         : Nadi              :                        x/menit

Suhu              :                        °C

Respirasi        :                        x/menit

c.       Panjang badan              :                        cm

d.      Berat badan                  :                        kg

e.       LILA                            :                        cm

f.       Lingkar kepala              :                        cm

g.      Lingkar dada                :                        cm

h.      Kepala-leher

Ø  Kepala                                                                                          

                                                                       

Ø  Ubun-ubun                                                                                                                                                                                                     

Ø  Sutura                                                                                           

                                                                       

Ø  Muka                                                                                                                                                                                                  

Ø  Mata                                                                                             

                                                                       

Ø  Hidung                                                                                                                                                                                               

Ø  Mulut/bibir                                                                                   

                                                                       

Ø  Telinga                                                                                                                                                                                                

Ø  Kulit                                                                                             

                                                                       

Ø  Leher                                                                                                                                                                                                  

i.        Thorak anterior             :                                                                      

                                                                                                                                               

j.        Abdomen anterior        :                                                                      

                                                                                                                                               

k.      Genetalia                      :                                                                      

                                                                                                                                               

l.        Anus                             :                                                                      

                                                                                                                                               

m.    Ekstrimitas                   :                                                                      

                                                                                                                                               

n.      Refleks

Ø  Sucking                 :                                                                      

Ø  Rooting                 :                                                                      

Ø  Graps                     :                                                                      

Ø  Moro                      :                                                                      

Ø  Tonic neck             :                                                                      

Ø  Babynski               :                                                                      

3.      Pemeriksaan penunjang

·         Pemeriksaan laboratorium

                                                                                                                                                                                                                                                                                                                    

·         Pemeriksaan rontgen

                                                                                                                                                                                                                                                                                                                    

ASUHAN KEBIDANAN KEHAMILAN             

PADA NY                   DENGAN                                        

DI                                 TAHUN                   

Tanggal           :

Waktu             :

Tempat            :

I.        PENGUMPULAN DATA

A.    DATA SUBJEKTIF

1.    Biodata

Nama (Istri)       :                                   Nama (Suami) :                      

Umur                 :                                   Umur               :                        

Agama               :                                   Agama             :                        

Pendidikan        :                                   Pendidikan      :                        

Pekerjaan           :                                   Pekerjaan         :                        

Suku bangsa      :                                   Suku bangsa    :                        

Alamat               :                                                                                  

Tanggal masuk/jam        :                                                                      

No. RM                         :                                                                        

2.      Alasan datang

                                                                                                                                                                                                                                                                                                                                            

3.      Keluhan utama

                                                                                                                                                                                                                                                                                                                                            

4.      Riwayat obstetric dan ginekologi

a.       Riwayat kehamilan, persalinan dan nifas yang lalu

Anak ke	Umur kehamilan	Jenis persalinan			Penolong persalinan	Nifas	JK	Kead. anak
		Spt	Tind	op				Hidup		Meninggal
								Umur	BBL	Umur	sebab

b.      Riwayat kehamilan sekarang

G         P         A                  

ANC               : TM I           :            kali

 TM II         :            kali

 TM III        :            kali

Imunisasi TT 1 :                     Tanggal :                  

  TT 2 :                    Tanggal :                  

Keluhan TM I         :                                                                                   Terapi yang diberikan         :                                              

        Nasehat yang diberikan          :                                              

Keluhan TM II        :                                                                      

        Terapi yang diberikan             :                                              

        Nasehat yang diberikan          :                                              

Keluhan TM III      :                                                                      

        Terapi yang diberikan             :                                              

        Nasehat yang diberikan          :                                              

c.       Riwayat haid

·         Menarche                      :                         Flaur Albus   :          

·         Siklus/Teratur                :                                   -Warna            :          

·         Lama/Jumlah                 :                                   -Bau    :          

·         Dysmenorhea                :                                   -Lama  :          

·         HPHT                           :                                   -Gatal  :          

·         HPL                              :                      

·         Umur kehamilan           :                      

d.      Riwayat penggunaan kontrasepsi

·         Jenis kontrasepsi                         :                                              

·         Lama                                           :                                              

·         Keluhan                                       :                                              

·         Alasan lepas                                :                                              

·         Rencana yang akan datang         :                                              

·         Alasan                                         :                                              

5.      Riwayat kesehatan

a.       Penyakit yang pernaah diderita

·         Penyakit infeksi              :                                                          

·         Penyakit keturunan         :                                                          

·         Kecelakaan/trauma          :                                                          

·         Riwayat operasi              :                                                          

·         Penyakit organ                :                                                          

b.      Kesehatan ibu sekarang

·         Penyakit infeksi              :                                                          

·         Penyakit keturunan         :                                                          

·         Penyakit organ                :                                                          

c.       Riwayat kesehatan keluarga

·         Penyakit infeksi              :                                                          

·         Penyakit keturunan         :                                                          

·         Penyakit organ                :                                                          

·         Riwayat gamelly             :                                                          

6.      Kebiasaan

·         Pantangan makan                   :                                                          

·         Minuman jamu                       :                                                          

·         Obat-obatan                           :                                                          

·         Miras/Rokok                          :                                                          

·         Memelihara binatang              :                                                          

7.      Kebutuhan sehari-hari (Sekarang             WIB)

a.       Pola nutrisi

·         Makan (x/hari)                                                                         

Porsi                                                                                         

Gangguan                                                                                

·         Minum (x/hari)                                                                         

Jenis                                                                                         

Gangguan                                                                                

b.      Pola eliminasi

·         BAB                                                                                        

Warna                                                                                      

Konsistensi                                                                              

Gangguan                                                                                

·         BAK                                                                                        

Warna                                                                                      

Gangguan                                                                                

c.       Pola istirahat

·         Siang                                                                                        

·         Malam                                                                                      

·         Gangguan                                                                                

d.      Pola aktivitas                                                                                  

e.       Pola personal hygiene

·         Mandi                                                                                      

·         Keramas                                                                                   

·         Gosok gigi                                                                               

·         Ganti baju                                                                                

f.       Pola seksual

·         Frekuensi                                                                                 

·         Gangguan                                                                                

8.      Data psikologis

·         Tanggapan ibu atas kehamilannya                                                  

·         Tanggapan suami dan keluarga                                                       

·         Kesiapan mental ibu                                                                       

9.      Data sosial ekonomi

·         Penghasilan                                                                                     

·         Tangguang jawab perekonomian                                                    

·         Pengambil keputusan                                                                      

10.  Data perkawinan

·         Perkawinan ke                                                                                

·         Lama perkawinan                                                                           

11.  Data spiritual

                                                                                                                                                                                                                                                                                                                                               

12.  Data sosial budaya

                                                                                                                                                                                                                                                                                                                                               

13.  Data pengetahuan ibu

                                                                                                                                                                                                                                                                                                                                               

B.     DATA OBYEKTIF

1.      Pemeriksaan Fisik

a.       Kesadaran                :                                                                      

b.      Keadaan umum       :                                                                      

c.       Tanda-tanda vital    : TD                 :                        mmHg

  Nadi              :                        x/menit

 Suhu               :                        °C

 Respirasi         :                        x/menit

d.      Tinggi badan            :                                    cm

e.       Berat badan             : Sebelum Hamil          :                        kg

Setelah Hamil            :                        kg

f.       LILA                       :                                    cm

g.      Status present

·         Kepala-Muka

Ø  Kepala                        :                                                                                                                                                                                                                                                         

Ø  Rambut                      :                                                          

                                                                                                                                               

Ø  Muka                          :                                                          

                                                                                                                                               

Ø  Mata                           :                                                          

Konjungtiva           :                                                          

Sklera                     :                                                          

Ø  Hidung                  :                                                          

                                                                                                                       

Ø  Mulut/bibir             :                                                          

                                                                                                                       

Ø  Telinga                   :                                                          

                                                                                                                       

·         Leher                                :                                                          

                                                                                                                       

·         Aksila                               :                                                          

                                                                                                                       

·         Dada                                :                                                          

Ø  Bentuk                       :                                                          

Ø  Mamae                       :                                                          

·         Abdomen                                    :                                                          

                                                                                                                       

·         Ekstrimitas                      :                                                          

                                                                                                                       

·         Genetalia                         :                                                          

                                                                                                                       

·         Anus                                :                                                          

                                                                                                                       

2.      Pemeriksaan Obstetri

a.       Isnpeksi

·         Muka                          :                                                          

                                                                                                                       

·         Mamae                        :                                                          

Ø  Puting susu          :                                                          

Ø  Kolostrum/ASI    :                                                          

Ø  Kebersihan          :                                                          

·         Abdomen                   :                                                          

                                                                                                                       

·         Genetalia                    :                                                          

                                                           

b.      Palpasi

·         Leopold I                      :                                                                                                                                                                                                                                                                                                                                                                          

·         Leopold II                    :                                                          

                                                                                                                                                                                   

·         Leopold III                   :                                                          

                                                                                                                                                                                   

·         Leopold IV                   :                                                          

                                                                                                                                                                                   

·         TBJ                               :                                                          

                                                                                                                                                                                   

c.       Auskultasi

DJJ                                                :                                                          

                                                          

d.      Perkusi

·         Reflek patella ka/ki    :                                                          

·         CVAT                                    :                                                          

e.       Pemeriksaan panggul luar

·         Distansia spinarum     :                                                          

·         Distansia krisnarum    :                                                          

·         Konjugata eksterna    :                                                          

·         Lingkar panggul         :                                                          

3.      Pemeriksaan penunjang

·         Pemeriksaan laboratorium

                                                                                                                                                                                                                                                                                                                                                                                                                                      

·         Pemeriksaan rontgen

                                                                                                                                                                                                                                                                                                                                                                                                                                      

·         USG

                                                                                                                                                                                                                                                                                                                                                                                                                                      

ASUHAN KEBIDANAN PERSALINAN

PADA NY                   DENGAN                                        

DI                                 TAHUN                   

Tanggal           :

Waktu             :

Tempat            :

I.     PENGUMPULAN DATA

A.    DATA SUBJEKTIF

1.      Biodata

Nama (Istri)           :                                   Nama (Suami) :                      

Umur                     :                                   Umur               :                      

Agama                   :                                   Agama             :                      

Pendidikan                        :                                   Pendidikan      :                      

Pekerjaan               :                                   Pekerjaan         :                      

Suku bangsa          :                                   Suku bangsa    :                      

Alamat                   :                                                                                  

Tanggal masuk/jam            :                                                                      

No. RM                             :                                                                        

2.      Alasan datang

                                                                                                                                                                                                                                                                                                                                                     

3.      Keluhan utama

                                                                                                                                                                                                                                                                                                                                                     

4.      Riwayat obstetric dan ginekologi

a.       Riwayat kehamilan, persalinan dan nifas yang lalu

Anak ke	Umur kehamilan	Jenis persalinan			Penolong persalinan	Nifas	JK	Kead. anak
		Spt	Tind	op				Hidup		Meninggal
								Umur	BBL	Umur	sebab

b.      Riwayat kehamilan sekarang

G            P         A                  

ANC       : TM I           :            kali

 TM II         :            kali

 TM III        :            kali

Imunisasi   TT 1 :                      Tanggal :                  

TT 2 :                      Tanggal :                  

Keluhan TM I              :                                                                                               Terapi yang diberikan                     :                                                                       Nasehat yang diberikan          :                                                

Keluhan TM II                        :                                                                      

        Terapi yang diberikan             :                                              

        Nasehat yang diberikan          :                                              

Keluhan TM III           :                                                          

        Terapi yang diberikan             :                                              

        Nasehat yang diberikan          :                                              

c.       Riwayat haid

·         Menarche                      :                         Flaur Albus   :          

·         Siklus/Teratur                :                                   -Warna            :          

·         Lama/Jumlah                 :                                   -Bau    :          

·         Dysmenorhea                :                                   -Lama  :          

·         HPHT                           :                                   -Gatal  :          

·         HPL                              :                      

·         Umur kehamilan           :                      

d.      Riwayat penggunaan kontrasepsi

·         Jenis kontrasepsi                         :                                              

·         Lama                                           :                                              

·         Keluhan                                       :                                              

·         Alasan lepas                                :                                              

·         Rencana yang akan datang         :                                              

·         Alasan                                         :                                              

5.      Riwayat kesehatan

a.       Penyakit yang pernaah diderita

·         Penyakit infeksi              :                                                          

·         Penyakit keturunan         :                                                          

·         Kecelakaan/trauma          :                                                          

·         Riwayat operasi              :                                                          

·         Penyakit organ                :                                                          

b.      Kesehatan ibu sekarang

·         Penyakit infeksi              :                                                          

·         Penyakit keturunan         :                                                          

·         Penyakit organ                :                                                          

c.       Riwayat kesehatan keluarga

·         Penyakit infeksi              :                                                          

·         Penyakit keturunan         :                                                          

·         Penyakit organ                :                                                          

·         Riwayat gamelly             :                                                          

6.      Kebiasaan

·         Pantangan makan                   :                                                          

·         Minuman jamu                       :                                                          

·         Obat-obatan                           :                                                          

·         Miras/Rokok                          :                                                          

·         Memelihara binatang              :                                                          

7.      Kebutuhan sehari-hari

Selama hamil               Sekarang (       WIB)

a.       Pola nutrisi

·         Makan (x/hari)                                                                            

Porsi                                                                                           

Gangguan                                                                                   

·         Minum                                                                                        

Jenis                                                                                           

Gangguan                                                                                   

b.      Pola eliminasi

·         BAB                                                                                           

Warna                                                                                         

Konsistensi                                                                                 

Gangguan                                                                                   

·         BAK                                                                                          

Warna                                                                                         

Gangguan                                                                                   

c.       Pola istirahat

·         Siang                                                                                          

·         Malam                                                                                        

·         Gangguan                                                                                   

d.      Pola aktivitas                                                                                     

e.       Pola personal hygiene

·         Mandi                                                                                         

·         Keramas                                                                                     

·         Gosok gigi                                                                                  

·         Ganti baju                                                                                  

f.       Pola seksual

·         Frekuensi                                                                                    

·         Gangguan                                                                                   

8.      Data psikologis

·         Tanggapan ibu atas kehamilannya     :                                              

·         Tanggapan suami dan keluarga          :                                              

·         Kesiapan mental ibu                           :                                              

9.      Data sosial ekonomi

·         Penghasilan                                        :                                              

·         Tanggung jawab perekonomian         :                                              

·         Pengambil keputusan                         :                                              

10.  Data perkawinan

·         Perkawinan ke                                    :                                              

·         Lama perkawinan                               :                                              

11.  Data spiritual

                                                                                                                                                                                                                                                                                                                                                     

12.  Data sosial budaya

                                                                                                                                                                                                                                                                                                                                                     

13.  Data pengetahuan ibu

                                                                                                                                                                                                                                                                                                                                                     

B.     DATA OBYEKTIF

1.      Pemeriksaan fisik

a.       Kesadaran                  :                                                                      

b.      Keadaan umum          :                                                                      

c.       Tanda-tanda vital       : TD                 :                        mmHg

Nadi               :                        x/menit

Suhu              :                        °C

Respirasi        :                        x/menit

d.      Tinggi badan              :                        cm

e.       Berat badan                : Sebelum hamil           :                        kg

Setelah hamil             :                        kg

f.       LILA                          :                        cm

g.      Status present

·         Kepala-muka

Ø  Kepala          :                                                                                                                                                                                                                                                                   

Ø  Rambut        :                                                                                                                                                                                                                                                                   

Ø  Muka            :                                                                                                                                                                                                                                                                   

Ø  Mata             :                                                                      

Konjungtiva :                                                                      

Sklera           :                                                                      

Ø  Hidung         :                                                                                                                                                                                                                                                                   

Ø  Mulut/bibir   :                                                                                                                                                                                                                                                                   

Ø  Telinga         :                                                                                                                                                                                                                                                                   

·         Leher                   :                                                                                                                                                                                                                                                                              

·         Dada                   :                                                                      

Ø  Bentuk         :                                                                      

Ø  Mamae         :                                                                      

·         Abdomen                        :                                                                                                                                                                                                                                                                              

·         Ekstrimitas          :                                                                                                                                                                                                                                                                              

·         Genetalia             :                                                                                                                                                                                                                                                                              

·         Anus                    :                                                                                                                                                                                                                                                                              

2.      Pemeriksaan obstetri

a.       Inspeksi

·    Muka                       :                                                                                                                                                                                                                                                                                      

·    Mamae                    :                                                                      

Ø Puting susu       :                                                                      

Ø Kolostrum/ASI :                                                                      

Ø Kebersihan        :                                                                      

·    Abdomen                :                                                                                                                                                                                                                                                                                      

·    Genetalia                 :                                                                                                                                                                                                                                                                                      

b.      Palpasi

·         Leopold I       :                                                                                                                                                                                                                                                                     

·         Leopold II      :                                                                                                                                                                                                                                                                     

·         Leopold III    :                                                                                                                                                                                                                                                                     

·         Leopold IV    :                                                                                                                                                                                                                                                                     

·         TBJ                 :                                                                      

·         Kontraksi

Ø  Frekuensi :                                                                      

Ø  Lama       :                                                                      

·         Bandle ring     :                                                                      

·         Vasika urinaria:                                                                     

c.       Auskultasi

DJJ                             :                                                                      

Punktum maximum    :                                                                      

d.      Perkusi

·         Reflek patella ka/ki         :                                                          

·         CVAT                             :                                                          

e.       Pemeriksaan panggul luar

·         Distansia spinarum          :                                                          

·         Distansia kristarum         :                                                          

·         Konjugata eksterna         :                                                          

·         Lingkar panggul              :                                                          

f.       Pemeriksaan dalam vagina

·         Tanggal/jam                     :

·         Oleh                                :

·         Indikasi                           :

·         Tujuan                             :

·         Hasil                                :

§  Vagina                      :

§  Porsio                       :

§  Effecement              :

§  Servik                       :

§  KK                           :

§  Penurunan                :

§  Titik penunjuk/PoD  :

§  Bag. Terkemuka/menumbung          :

g.      Pemeriksaan panggul dalam

·         Promontorium teraba/tidak         :                                              

·         Konjugata vera                            :                                              

·         Tanda goodell                             :                                              

3.      Pemeriksaan penunjang

·         Pemeriksaan laboratorium

                                                                                                                                                                                                                                                                                                                                                                                                                                      

·         Pemeriksaan rontgen

                                                                                                                                                                                                                                                                                                                                                                                                                                      

·         USG