ASUHAN KEBIDANAN PADA IBU BERSALIN
NORMAL
NO.
REGISTER : ………………….................................................
MASUK RS TANGGAL : …………………………………………………..
DIRAWAT DI RUANG : .............................................................................
PENGKAJIAN DATA
a. Biodata Ibu Suami
1. Nama :
..................................... ..............................
2. Umur :
..................................... ..............................
3. Agama : ..................................... ..............................
4. Suku/bangsa : ..................................... ..............................
5. Pendidikan : ..................................... ..............................
6. Pekerjaan : ..................................... ..............................
7. Alamat : ..................................... ..............................
8. Perkawinan : ..................................... ..............................
9. Lama :
..................................... ..............................
b. Data Subjektif
1. Alasan masuk kamar bersalin
..................................................................................................................................................................................................................................................
2. Keluhan utama
..................................................................................................................................................................................................................................................
3. Tanda-tanda persalinan
a. Kontraksi uterus sejak tanggal
.................................. jam............, Frekuensi :
......... kali dalam 10 menit
Durasi : ............. detik
Kekuatan : kuat/sedang/lemah
Lokasi ketidaknyamanan di
.....................................................................
b. Pengeluaran per vaginam
Lendir darah :
ya/tidak
Air ketuban :
ya/tidak, banyaknya .............. cc, warna ..................
Darah :
ya/tidak, banyaknya .............. cc, warna ..................
4. Riwayat sebelum masuk ruang bersalin
5. Riwayat kehamilan sekarang
HPM
................................................... HPL
.................................................
Menarche umur ................... tahun,
siklus .............. hari, lama ............ hari,
Banyaknya ..................... cc
ANC teratur/tidak, frekuensi
................. kali, di............................................
Keluhan/komplikasi selama kehamilan:
................................................................................................................................................................................................................................................
Riwayat merokok/minum-minuman keras/minum
jamu ...............................
Imunisasi TT 1 : ya/tidak, tanggal .......................
Imunisasi TT 2 : ya/tidak, tanggal .......................
6. Pergerakan janin dalam 24 jam terakhir
................ kali
7. Makan terakhir tanggal
........................... jam .......... Jenis ...........................
8. Buang air besar terakhir
tanggal......................... jam ............
9. Buang air kecil terakhir
tanggal.......................... jam ............
10. Istirahat/tidur dalam 1 hari terakhir
.................... jam
11. Kondisi Psikologis/Kesiapan menghadapi
proses persalinan
..................................................................................................................................................................................................................................................
12. Riwayat kehamilan, persalinan dan nifas
yang lalu
|
Hamil ke
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Persalinan
|
Nifas
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Tgl lahir
|
Umur kehamilan
|
Jenis persalinan
|
penolong
|
komplikasi
|
Jenis kelamin
|
BB lahir
|
laktasi
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komplikasi
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13. Riwayat kontrasepsi yang digunakan
|
No
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Jenis kontrasepsi
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Pasang
|
Lepas
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tanggal
|
oleh
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tempat
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keluhan
|
tanggal
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oleh
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tempat
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Alasan
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14. Riwayat kesehatan
a. Penyakit yang pernah/sedang diderita
....................................................................................................................................................................................................................................
b. Penyakit yang pernah/sedang diderita
keluarga
....................................................................................................................................................................................................................................
c. Riwayat keturunan kembar
....................................................................................................................................................................................................................................
c. Data Objektif
1. Pemeriksaan Fisik
a. Keadaan umum
.............................. kesadaran
........................................
b. Status emosional :
...................................................................................
c. Tanda vital
Tekanan darah :
...................................................................................
Nadi :
...................................................................................
Pernafasan :
...................................................................................
Suhu :
...................................................................................
d. BB/TB/LLA :
...................................................................................
e. Kepala dan leher
Oedem wajah : ...................................................................................
Cloasma gravidarum + / -
Mata :
...................................................................................
Mulut :
...................................................................................
Leher :
...................................................................................
f.
Payudara
Bentuk :
...................................................................................
Puting susu : ...................................................................................
Colostrum :
...................................................................................
g. Abdomen
Bentuk :
...................................................................................
Bekas luka :
...................................................................................
Strie gravidarum :
...................................................................................
Palpasi Leopold
Leopold I : ...................................................................................
Leopold II :
...................................................................................
Leopold III :
...................................................................................
Leopold IV : ...................................................................................
Osborn test :
...................................................................................
TBJ :
...................................................................................
Auskultasi DJJ :
Punctum maksimum .................................................
Frekuensi: .................kali per menit
(.... / .... / ....)
His :
Frekuensi : ......... kali dalam 10 menit
Durasi :
............. detik
Kekuatan :
kuat/sedang/lemah
Palpasi
supra pubik:
................................................................................
h. Pinggang : nyeri/tidak
i.
Tangan
dan kaki
Oedem :
...................................................................................
Varices :
...................................................................................
Reflek patela :
...................................................................................
Kuku :
...................................................................................
j.
Genetalia
luar
Tanda chadwich :
...................................................................................
Varices :
...................................................................................
Bekas luka : ...................................................................................
Kelenjar bartholini:
.................................................................................
Pengeluaran :
...................................................................................
k. Anus
Hemoroid :
...................................................................................
2. Pemeriksaan Panggul Luar (bila perlu)
.........................................................................................................................
.........................................................................................................................
3. Pemeriksaan Dalam, tanggal
..................................., oleh ............................ Indikasi : ...............................................................................................
Tujuan :
...............................................................................................
Hasil : ...............................................................................................
.........................................................................................................................
4. Pemeriksaan Penunjang
a. Pemeriksaan Laboratorium
Darah, tanggal:
Hasil ........................................................................................................
..................................................................................................................
Urine, tanggal:
Hasil ........................................................................................................
................................................................................................................
b. Pemeriksaan Radiologi
USG/foto rontgent/NST/amniosintesis,
tanggal:
Hasil
........................................................................................................
..................................................................................................................
c. Catatan Medik lain
..................................................................................................................
..................................................................................................................
II.
INTERPRETASI
DATA
a. Diagnosa kebidanan
..............................................................................................................................................................................................................................................................
Data Dasar:
.............................................................................................................................................................................................................................................................
b. Masalah
..............................................................................................................................................................................................................................................................
Data Dasar:
..............................................................................................................................................................................................................................................................
c. Kebutuhan
..............................................................................................................................................................................................................................................................
Data Dasar:
..............................................................................................................................................................................................................................................................
III.
IDENTIFIKASI
DIAGNOSA/MASALAH POTENSIAL DAN ANTISIPASI PENANGANAN
a. Diagnosa Potensial
..............................................................................................................................................................................................................................................................
Data Dasar:
............................................................................................................................................................................................................................................................
b. Masalah Potensial
..............................................................................................................................................................................................................................................................
Data Dasar:
...........................................................................................................................................................................................................................................................
c. Antisipasi
..............................................................................................................................................................................................................................................................
IV.
MENETAPKAN
KEBUTUHAN TERHADAP TINDAKAN SEGERA BERDASARKAN KONDISI KLIEN
a. Mandiri
..............................................................................................................................................................................................................................................................
b. Kolaborasi
..............................................................................................................................................................................................................................................................
c. Merujuk
..............................................................................................................................................................................................................................................................
V.
RENCANA
ASUHAN YANG MENYELURUH, tanggal ............................jam .......
a.
.............................................................................................................................
b.
..............................................................................................................................
c.
..............................................................................................................................
VI IMPLEMENTASI Tanggal ............................... jam .......... .
a.
.............................................................................................................................
b.
..............................................................................................................................
c.
.........................................................................................................................
VII EVALUASI Tanggal ............................... jam .......... ...
- ....................................................................................................................................
- ....................................................................................................................................
- .....................................................................................................................................
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