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ASUHAN KEBIDANAN PADA KELUARGA BERENCANA (KB)

No MR :
Masuk tgl/jam :

PENGKAJIAN Tgl/jam ...................................................


I. SUBYEKTIF
1. Identitas
Istri Suami
Nama : .................................... ....................................
Umur : .................................... ....................................
Agama : .................................... ....................................
Pendidikan : .................................... ....................................
Pekerjaan : .................................... ....................................
Suku/bangsa : .................................... ....................................
Alamat : .................................... ....................................
Telp : .................................... ....................................

2. Anamnesa
a. Keluhan Utama .........................................................................................................
b. Riwayat Perkawinan
Perkawinan ke : .............................................
Menikah sejak umur : .............................................
Lama perkawinan : .............................................
Status perkawinan : ............................................
c. Riwayat Haid
Menarche : ...............................................
Lama menstruasi : .............................................
Teratur /tidak : .............................................
Sakit /tidak : .............................................
Siklus : .............................................
HPHT : .............................................
HPL : .............................................
d. Riwayat Obstetrik
G ..........P........A........Ah.........
Jenis BB
No Thn UK Penolong Tempat H/M L/P Komplikasi
persalinan lahir

e. Riwayat KB
Pasang Lepas
No
Metode Tgl Petugas Tempat Tgl Petugas Tempat Alasan

f. Riwayat Kesehatan
a) Riwayat kesehatan yang lalu
................................................................................................................................
................................................................................................................................
................................................................................................................................
...............................................................................................................................
b) Riwayat kesehatan sekarang
................................................................................................................................
................................................................................................................................
................................................................................................................................
...............................................................................................................................
c) Riwayat kesehatan keluarga
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................

g. Riwayat persalinan terakhir


Kala Lama Tindakan Perdarahan Keterangan

h. Pola Kebutuhan Sehari-hari


1) Nutrisi
Nutrisi Makan Minum
Frekuensi makan sehari
Jenis
Porsi
Keluhan

2) Eliminasi
Eliminasi BAK BAB
Frekuensi
Warna
Jumlah
Keluhan

3) Istirahat
Istirahat Siang Malam
Aktifitas
Personal hygiene
Pola seksual
Keluhan

i. Data Psikososial Spriritual


1) Pengetahuan ibu dan keluarga tentang kontrasepsi : ............................................
2) Pengambilan keputuhan oleh : ............................................................................
3) Ketaatan ibu beribadah : .....................................................................................
4) Ibu tinggal bersama : ..........................................................................................
5) Hewan peliharaan : .............................................................................................

II. OBYEKTIF
1. Pemeriksaan Umum
KU : .................................................................................................................
Kesadaran : .................................................................................................................
TB : .................................................................................................................
BB : Sebelum hamil : ................................. Setelah hamil ..............................
LILA : .................................................................................................................
Vital sign : T : ...................... N : ........................ S : .................... R : .....................

2. Pemeriksaan Obstetrik
Kepala : .................................................................................................................
Muka : .................................................................................................................
Mata : .................................................................................................................
Telinga : .................................................................................................................
Mulut : .................................................................................................................
Hidung : .................................................................................................................
Leher : .................................................................................................................
Aksila : .................................................................................................................
Payudara : .................................................................................................................
Abdomen :
Leopold I : .......................................................................................................
Leopold II : .......................................................................................................
Leopold III : ......................................................................................................
Leopold IV : ......................................................................................................
TBJ : ......................................................................................................
Djj : ......................................................................................................
Genetalia : ......................................................................................................
Ekstrimitas :
Tangan : ......................................................................................................
Kaki : ................................................................(reflek patela kanan/kiri)

3. Pemeriksaan Penunjang
Urine : tgl ................................ (Pptest, Protein, Glukosa, dll)
Darah : tgl ................................(Hb, Al, HMT, Golongan darah)

III.ANALISA

IV. PENATALAKSANAAN

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