AKADEMI KEBIDANAN NYAI AHMAD DAHLAN YOGYAKARTA

SK MENKES RI No : HK.03.2.4.1.04569, SK MENDIKNAS RI No : 003/D/O/2008

ALAMAT : Jl. Wates Km.9,5 Plawonan Argomulyo Sedayu Bantul Yogyakarta 55753 TELP (0274) 6498250
e-mail : akbid_nad@yahoo.com

ASUHAN KEBIDANAN IBU HAMIL PATOLOGIS

PADA Ny ..... G ..... P ..... A ..... Ah ..... HAMIL ....... mgg ....... hr
DI RSIA SAKINA IDAMAN

Nama Mahasiswa : Sri Mulyani

NIM : 0613137
Ketrampilan ke : ....................

S Tanggal : ........................... Jam : ..........WIB No RM : .............................

1. Identitas pasien dan penanggung jawab

Ibu Suami
Nama : ..................................................... ......................................................
Umur : ..................................................... ......................................................
Agama : ..................................................... ......................................................
Pendidikan : ..................................................... ......................................................
Pekerjaan : ..................................................... ......................................................
Suku Bangsa : ..................................................... ......................................................
Alamat : ..................................................... ......................................................
..................................................... .......................................................
Keluhan : .....................................................................................................................
................................................................................................................................................

2. Riwayat kesehatan
a. Riwayat kesehatan keluarga : .................................................................................
..........................................................................................................................................
..........................................................................................................................................
b. Riwayat kesehatan yang : .................................................................................
..........................................................................................................................................
..........................................................................................................................................
c. Riwayat kesehatan sekarang : .................................................................................
..........................................................................................................................................
..........................................................................................................................................

3. Riwayat Obstetri
a. Haid
Menarche ...... th, siklus ...... hr, teratur/tidak, sakit/tidak, lama ...... hr, encer/beku
Flour albus ........................................................................................................................
..........................................................................................................................................
HPHT ................................................... HPL....................................................

b. Riwayat persalinan yang lalu

No Tahun U Jenis Penolong Tempat H/M JK BBL Komplikasi Ket
K persalinan .
 c. Riwayat kehamilan sekarang
G ...... P ...... A ...... Ah ...... Hamil ....... mgg ....... hr, TM ......
T Masalah/keluhan KIE Frek. Terapi
M
I
II
III

Status Imunisasi TT : .................................................................................

..................................................................................

4. Riwayat KB
a. Kontrasepsi : .................................................................................
..................................................................................
b. Alasan berhenti : .................................................................................
c. Rencana yang akan digunakan : .................................................................................
..................................................................................

5. Riwayat Pernikahan
Pernikahan ke ......, lama ...... th

6. Pola kebutuhan sehari-hari

a. Pola nutrisi
makan minum
Porsi : ...................................................... .....................................................
Jenis : ...................................................... .....................................................
Frekuensi : ...................................................... .....................................................
Masalah : ...................................................... .....................................................
b. Pola eliminasi
BAB BAK
Frekuensi : ...................................................... .....................................................
Warna : ...................................................... .....................................................
Keluhan : ...................................................... .....................................................
c. Pola istirahat
Tidur siang ....... jam Tidur malam ....... jam
d. Pola aktivitas
..........................................................................................................................................
..........................................................................................................................................
e. Pola hubungan seksual
..........................................................................................................................................
Keluhan : .....................................................................................................................
f. Pola personal hygiene
Mandi ....... x/hr, ganti pakaian dalam ....... x/hr
Keramas ........... x/mgg, gosok gigi ...........x/hr

7. Psikososial spiritual
Tanggapan ibu dan keluarga tentang kehamilan
................................................................................................................................................
................................................................................................................................................
Pengetahuan ibu dan keluarga tentang kehamilan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Ketaatan beribadah ..................................................................................................................
 Pengambilan keputusan ............................................................................................................
................................................................................................................................................
Ibu tinggal bersama .................................................................................................................
Hewan peliharaan ....................................................................................................................
................................................................................................................................................
Rencana persalinan ..................................................................................................................
................................................................................................................................................

O Tanggal : ............................. Jam : ........... WIB

1. Pemeriksaan umum
KU : ...........................
Kesadaran : ...........................
TD : ................. mm/Hg
N : ................. x/menit
S : ................. C
RR : ................. x/menit
BB sebelum hamil : ................. Kg
BB sekarang : ................. Kg
TB : ................. cm
LILA : ................. cm

2. Pemeriksaan Fisik
Inspeksi
a. Kepala : .........................................................................................................
..........................................................................................................
b. Mata : .........................................................................................................
c. Mulut dan gigi : .........................................................................................................
..........................................................................................................
d. Leher : .........................................................................................................
..........................................................................................................
e. Payudara : .........................................................................................................
..........................................................................................................
f. Abdomen : .........................................................................................................
g. Panggul : .........................................................................................................
h. Genetalia : .........................................................................................................
..........................................................................................................
i. Ekstremitas bawah : .........................................................................................................
Perkusi : Reflek patella kanan/kiri : ....... / ........

3. Status Obstetri
a. Inspeksi : .........................................................................................................
..........................................................................................................
..........................................................................................................
..........................................................................................................
b. Palpasi
Leopold I : .........................................................................................................
..........................................................................................................
..........................................................................................................

Leopold II : .........................................................................................................
..........................................................................................................
..........................................................................................................
Leopold III : .........................................................................................................
 ..........................................................................................................
..........................................................................................................
Leopold IV : .........................................................................................................
..........................................................................................................
..........................................................................................................

Mc Donald : TFU ............ cm

TBJ : ............................................... gram
c. Auskultasi : DJJ ............... x/menit, teratur/tidak

4. Data Penunjang
a. Hb : .........................................................
b. Urine rutin
Protein : .........................................................
Reduksi : .........................................................
c. USG : .........................................................................................................
..........................................................................................................
d. Pemeriksaan pelvimeter/panggul
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

A Tanggal : ........................... Jam : ..........WIB

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P Tanggal : ........................... Jam : ..........WIB

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Yogyakarta, ....................................................

Pembimbing Akademik Pembimbing Lahan Mahasiswa

( Nurul Ariningtyas SST ) ( Rodiah SST ) ( Sri Mulyani )

AKADEMI KEBIDANAN NYAI AHMAD DAHLAN YOGYAKARTA
SK MENKES RI No : HK.03.2.4.1.04569, SK MENDIKNAS RI No : 003/D/O/2008
ALAMAT : Jl. Wates Km.9,5 Plawonan Argomulyo Sedayu Bantul Yogyakarta 55753 TELP (0274) 6498250
e-mail : akbid_nad@yahoo.com

ASUHAN KEBIDANAN IBU HAMIL PATOLOGIS

PADA Ny ..... G ..... P ..... A ..... Ah ..... HAMIL ....... mgg ....... hr
DI RSIA SAKINA IDAMAN

Nama Mahasiswa : Sri Muslimatun

NIM : 0613138
Ketrampilan ke : ....................

S Tanggal : ........................... Jam : ..........WIB No RM : .............................

1. Identitas pasien dan penanggung jawab

Ibu Suami
Nama : ..................................................... ......................................................
Umur : ..................................................... ......................................................
 Agama : ..................................................... ......................................................
Pendidikan : ..................................................... ......................................................
Pekerjaan : ..................................................... ......................................................
Suku Bangsa : ..................................................... ......................................................
Alamat : ..................................................... ......................................................
..................................................... .......................................................
Keluhan : .....................................................................................................................
................................................................................................................................................

2. Riwayat kesehatan
d. Riwayat kesehatan keluarga : .................................................................................
..........................................................................................................................................
..........................................................................................................................................
e. Riwayat kesehatan yang : .................................................................................
..........................................................................................................................................
..........................................................................................................................................
f. Riwayat kesehatan sekarang : .................................................................................
..........................................................................................................................................
..........................................................................................................................................

3. Riwayat Obstetri
d. Haid
Menarche ...... th, siklus ...... hr, teratur/tidak, sakit/tidak, lama ...... hr, encer/beku
Flour albus ........................................................................................................................
..........................................................................................................................................
HPHT ................................................... HPL....................................................

P Tanggal : ........................... Jam : ..........WIB

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............................................................................................................................................................
Yogyakarta, ....................................................

Pembimbing Akademik Pembimbing Lahan Mahasiswa

( Nurul Ariningtyas SST ) ( Rodiah SST ) ( Sri Muslimatun )

AKADEMI KEBIDANAN NYAI AHMAD DAHLAN YOGYAKARTA
SK MENKES RI No : HK.03.2.4.1.04569, SK MENDIKNAS RI No : 003/D/O/2008
ALAMAT : Jl. Wates Km.9,5 Plawonan Argomulyo Sedayu Bantul Yogyakarta 55753 TELP (0274) 6498250
e-mail : akbid_nad@yahoo.com

ASUHAN KEBIDANAN IBU HAMIL ....................

PADA Ny ..... G ..... P ..... A ..... Ah ..... HAMIL ....... mgg ....... hr
DI RSIA SAKINA IDAMAN

Nama Mahasiswa : Sri Mulyani

NIM : 0613137
Ketrampilan ke : ....................

I. PENGKAJIAN
Tanggal : ........................... Jam : ..........WIB No RM : .............................

A. Data Subyektif

1. Identitas pasien dan penanggung jawab

Ibu Suami
Nama : ..................................................... ......................................................
Umur : ..................................................... ......................................................
Agama : ..................................................... ......................................................
Pendidikan : ..................................................... ......................................................
Pekerjaan : ..................................................... ......................................................
 Suku Bangsa : ..................................................... ......................................................
Alamat : ..................................................... ......................................................
..................................................... .......................................................
Keluhan : .....................................................................................................................
................................................................................................................................................

2. Riwayat kesehatan
a. Riwayat kesehatan keluarga : ..................................................................................
....................................................................................................................................
...............................................................................................................................
b. Riwayat kesehatan yang : .................................................................................
....................................................................................................................................
....................................................................................................................................
c. Riwayat kesehatan sekarang : .................................................................................
....................................................................................................................................
....................................................................................................................................

3. Riwayat Obstetri
a. Haid
Menarche ...... th, siklus ...... hr, teratur/tidak, sakit/tidak, lama ...... hr, encer/beku
Flour albus
....................................................................................................................................
....................................................................................................................................
HPHT ................................................. HPL..................................................

b. Riwayat persalinan yang lalu

No Tahun U Jenis Penolong Tempat H/M JK BBL Komplikasi Ket
K persalinan .

c. Riwayat kehamilan sekarang

G ...... P ...... A ...... Ah ...... Hamil ....... mgg ....... hr, TM ......
T Masalah/keluhan KIE Frek. Terapi
M
I
II
III

Status Imunisasi TT : .................................................................................

..................................................................................

d. Riwayat KB
Kontrasepsi : .................................................................................
..................................................................................
Alasan berhenti : .................................................................................
Rencana yang akan digunakan : .................................................................................
..................................................................................

4. Riwayat Pernikahan
Pernikahan ke ......, lama ...... th

5. Pola kebutuhan sehari-hari

a. Pola nutrisi
makan minum
 Porsi : ................................................ ...............................................
Jenis : ................................................ ...............................................
Frekuensi : ................................................ ...............................................
Masalah : ................................................ ...............................................
b. Pola eliminasi
BAB BAK
Frekuensi : ................................................ ...............................................
Warna : ................................................ ...............................................
Keluhan : ................................................ ...............................................
c. Pola istirahat
Tidur siang ....... jam Tidur malam ....... jam
d. Pola aktivitas
....................................................................................................................................
....................................................................................................................................
e. Pola hubungan seksual
....................................................................................................................................
Keluhan : .........................................................................................................
f. Pola personal hygiene
Mandi ....... x/hr, ganti pakaian dalam ....... x/hr
Keramas ........... x/mgg, gosok gigi ...........x/hr

6. Psikososial spiritual
Tanggapan ibu dan keluarga tentang kehamilan
...........................................................................................................................................
...........................................................................................................................................
Pengetahuan ibu dan keluarga tentang kehamilan
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Ketaatan beribadah ..............................................................................................................
Pengambilan keputusan
...........................................................................................................................................
...........................................................................................................................................
Ibu tinggal bersama .............................................................................................................
Hewan peliharaan ...............................................................................................................
Rencana persalina ...............................................................................................................
...........................................................................................................................................

B. Data Obyektif
1. Pemeriksaan umum
KU : ...........................
Kesadaran : ...........................
TD : ................. mm/Hg
N : ................. x/menit
S : ................. C
RR : ................. x/menit
BB sebelum hamil : ................. Kg
BB sekarang : ................. Kg
TB : ................. cm
LILA : ................. cm

2. Pemeriksaan Fisik
Inspeksi
a. Kepala : .........................................................................................................
..........................................................................................................
b. Mata : .........................................................................................................
c. Mulut dan gigi : .........................................................................................................
..........................................................................................................
d. Leher : .........................................................................................................
 ..........................................................................................................
e. Payudara : .........................................................................................................
..........................................................................................................
f. Abdomen : .........................................................................................................
g. Panggul : .........................................................................................................
h. Genetalia : .........................................................................................................
..........................................................................................................
i. Ekstremitas bawah : .....................................................................................................
....................................................................................................................................
Perkusi : Reflek patella kanan/kiri : ....... / ........

3. Status Obstetri
a. Inspeksi : .........................................................................................................
..........................................................................................................
..........................................................................................................
..........................................................................................................
b. Palpasi
Leopold I : .........................................................................................................
..........................................................................................................
..........................................................................................................
Leopold II : .........................................................................................................
..........................................................................................................
..........................................................................................................
Leopold III : .........................................................................................................
..........................................................................................................
..........................................................................................................
Leopold IV : .........................................................................................................
..........................................................................................................
..........................................................................................................

Mc Donald : TFU ............ cm

TBJ : ............................................... gram
c. Auskultasi : DJJ ............... x/menit, teratur/tidak

C. Data Penunjang
Hb : .........................................................
Urine rutin
Protein : .........................................................
Reduksi : .........................................................
USG : .....................................................................................................................
......................................................................................................................

Pemeriksaan pelvimeter/panggul
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

II. INTERPRESTASI DATA

A. Diagnosa Kebidanan
..............................................................................................................................................
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 B. Masalah
..............................................................................................................................................
C. Kebutuhan
..............................................................................................................................................

III. DIAGNOSA POTENSIAL

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IV.ANTISIPASI TINDAKAN SEGERA

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V. INTERVENSI
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VI. IMPLEMENTASI
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VII. EVALUASI
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Yogyakarta, ....................................................

Pembimbing Akademik Pembimbing Lahan Mahasiswa

( Nurul Ariningtyas SST ) ( Rodiah SST ) ( Sri Mulyani )

 AKADEMI KEBIDANAN NYAI AHMAD DAHLAN YOGYAKARTA
SK MENKES RI No : HK.03.2.4.1.04569, SK MENDIKNAS RI No : 003/D/O/2008
ALAMAT : Jl. Wates Km.9,5 Plawonan Argomulyo Sedayu Bantul Yogyakarta 55753 TELP (0274) 6498250
e-mail : akbid_nad@yahoo.com

ASUHAN KEBIDANAN IBU HAMIL .....................

PADA Ny ..... G ..... P ..... A ..... Ah ..... HAMIL ....... mgg ....... hr
DI RSIA SAKINA IDAMAN

Nama Mahasiswa : Sri Muslimatun

NIM : 0613138
Ketrampilan ke : ....................

I. PENGKAJIAN
Tanggal : ........................... Jam : ..........WIB No RM : .............................

A. Data Subyektif

1. Identitas pasien dan penanggung jawab

Ibu Suami
Nama : ..................................................... ......................................................
Umur : ..................................................... ......................................................
Agama : ..................................................... ......................................................
Pendidikan : ..................................................... ......................................................
Pekerjaan : ..................................................... ......................................................
Suku Bangsa : ..................................................... ......................................................
Alamat : ..................................................... ......................................................
..................................................... .......................................................
Keluhan : .....................................................................................................................
................................................................................................................................................

2. Riwayat kesehatan
a. Riwayat kesehatan keluarga : ..................................................................................
....................................................................................................................................
...............................................................................................................................
b. Riwayat kesehatan yang : .................................................................................
....................................................................................................................................
....................................................................................................................................
c. Riwayat kesehatan sekarang : .................................................................................
....................................................................................................................................
....................................................................................................................................

3. Riwayat Obstetri
a. Haid
Menarche ...... th, siklus ...... hr, teratur/tidak, sakit/tidak, lama ...... hr, encer/beku
Flour albus
....................................................................................................................................
....................................................................................................................................
HPHT ................................................. HPL..................................................
VIII. EVALUASI
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....................................................................................................................................................

Yogyakarta, ....................................................

Pembimbing Akademik Pembimbing Lahan Mahasiswa

( Nurul Ariningtyas SST ) ( Rodiah SST ) ( Sri Muslimatun )