Askeb Yappi 2017

DAFTAR PENCAPAIAN TARGET KOMULATIF PRAKTIK KLINIK KEBIDANAN
AKADEMI KEBIDANAN YAPPI SRAGEN
NO TARGET JUMLAH
1 KEHAMILAN 100 kasus
A. Kehamilan Fisiologis
TM I 20 kasus
TM II 30 kasus
TM III 50 kasus
B. Kehamilan Patologis 20 kasus
TM I 5 kasus
TM II 5 kasus
TM III 10 kasus
2 Persalinan 60 kasus
A. Persalinan Fisiologis 50 kasus
B. Persalinan Patologis 10 kasus
3 Bayi Baru Lahir 60 kasus
A. Fisiologis 50 kasus
B. Patologis 10 kasus
4 Nifas 60 kasus
5 Tumbang Balita 10 kasus
6 KB (dengan keluhan/tanpa keluhan) 50 kasus
A. AKDR 5 kasus
B. AKBK 5 kasus
C. SUNTIK 15 kasus
D. PIL 15 kasus
E. SEDERHANA (tanpa/dengan 5 kasus
alat) 2 kasus
F. Pre/Post MOP 3 kasus
G. Pre/Post MOW
7 KEBIDANAN KOMUNITAS 15 kasus
A. Persalinan di rumah 2 kasus
B. Persalinan DOMINO 2 kasus
C. Nifas di rumah 6 kasus
D.Penyuluhan Ibu dan Anak 5 kasus
TOTAL TARGET 375 kasus
1
BUKU PANDUAN PRAKTIK KLINIK KEBIDANAN
DAFTAR PENCAPAIAN TARGET KOMULATIF PRAKTIK KLINIK KEBIDANAN
AKADEMI KEBIDANAN YAPPI SRAGEN
PKK PKK PKK PKK JUMLAH

NO TARGET
IIA IIB IIIA IIIB TARGET
1 KEHAMILAN
A. Kehamilan Fisiologis
TM I 10 5 5 - 20
TM II 10 10 5 5 30
TM III 20 15 15 - 50
B. Kehamilan Patologis
TM I - 3 2 - 5
TM II - 3 2 - 5
TM III - 5 5 - 10
2 Persalinan
A. Persalinan Fisiologis 20 13 13 4 50
B. Persalinan Patologis - 10 - - 10
3 Bayi Baru Lahir
A. Fisiologis 20 20 10 - 50
B. Patologis - 5 5 - 10
4 Nifas
A. Fisiologis 20 13 13 4 50
5 Tumbang Balita
A. Fisiologis 3 - 2 - 5
6 KB (dengan keluhan/tanpa keluhan)
A. AKDR 2 1 1 1 5
B. AKBK 2 1 1 1 5
C. SUNTIK 10 2 2 1 15
D. PIL 10 2 2 1 15
E. SEDERHANA (tanpa/dengan alat) 2 1 1 1 5
F. Pre/Post MOP - 1 1 - 2
G. Pre/Post MOW - 2 1 - 3
7 KEBIDANAN KOMUNITAS
A. Persalinan di rumah - - - - -
B. Persalinan DOMINO - - - - -
C. Nifas di rumah - - - - -
D.Penyuluhan Ibu dan Anak - - - - -
2
YAYASAN PONDOK DAN PENDIDIKAN ISLAM
AKADEMI KEBIDANAN YAPPI
Kampus : Jl. KH. Agus Salim No 50 Mojomulyo Sragen Telp./Fax : (0271) 890478
E-Mail : akbidyappi@yahoo.com, Website : www.akbidyappi.ac.id
SRAGEN – JAWA TENGAH
ASUHAN KEBIDANAN IBU HAMIL

........................................................................................................
........................................................................................................
Tanggal Masuk : ........................................................ Jam : ....................
Tempat Pengkajian : .........................................................................................
No. Register : .........................................................................................
.
I. PENGKAJIAN
Tanggal ................................... Jam ..........................................
A. Data Subjektif
1. Identitas
1. Identitas Pasien
ISTRI SUAMI
1) Nama : ........................................ .................................
2) Umur : ........................................ .................................
3) Pendidikan : ........................................ .................................
4) Pekerjaan : ........................................ .................................
5) Alamat : ................................................................................
2. Alasan Datang/Keluhan : ................................................................................

................................................................................
3. Data Kebidanan
a. Riwayat Menstruasi
1) Menarche : ................................................................................
2) Siklus : ................................................................................
3) Lama : ................................................................................
4) Banyak Darah : ................................................................................
5) Bau : ................................................................................
6) Warna : ................................................................................
7) Konsistensi : ................................................................................
8) Dismenorhoe : ................................................................................
9) Flour Albus : ................................................................................
3
b. Riwayat Kehamilan, Persalinan dan Nifas yang Lalu
Hamil Tahun Umur Jenis Penolong Tempat Komplikasi JK/BB /PB Kead Laktasi Penyulit
ke- lahir Khmln Persalinan Skrng Nifas
c. Riwayat Kehamilan Sekarang

1) G...P....A... : ................................................................................
2) HPHT : ................................................................................
3) HPL : ................................................................................
4) Umur Kehamilan : ................................................................................
5) Tempat ANC : ................................................................................
6) ANC Teratur / Tidak : ........... kali (TM I :......x, ; II: .....x ; III: .......)
7) Keluhan :
a) TM I : ............................................................. Terapi
b) TM II : ............................................................ Terapi
c) TM III : ........................................................... Terapi
8) Gerakan janin yang pertama kali…......bulan, gerakan janin sekarang…..........
(aktif/jarang)
9) Imunisasi :
a) TT I : tanggal ........................................
b) TT II : tanggal ........................................
c) TT III : tanggal ........................................
d) TT IV : tanggal ........................................
e) TT V : tanggal ........................................
10) Obat-obatan yang dikonsumsi : ........................................
11) Penyuluhan yang pernah didapat :..............................................
4
12) Rencana Persalinan
a) Tempat : ...............................................................
b) Penolong : ...............................................................
c) Pendamping : ...............................................................
d) Donor : ...............................................................
e) Transportasi : ...............................................................
f) Biaya : ...............................................................
d. Riwayat KB
1) Jenis alkon : .............................................................
2) Lama penggunaan : .............................................................
3) Efek samping : .............................................................
4) Alasan berhenti : .............................................................
e. Status Perkawinan
1) Nikah : …....kali
2) Umur : …....tahun
3) Umur Suami : .…...tahun
4) Lama pernikahan : ........tahun
4. Riwayat Kesehatan
a. Data Kesehatan Sekarang : ........................................................
...........................................................................................................
b. Riwayat Kesehatan Dahulu
1) Jantung : ........................................................
2) Hipertensi : ........................................................
3) Asma : ........................................................
4) Tubercolusis : ........................................................
5) Ginjal : ........................................................
6) Diabetes Militus : ........................................................
7) Malaria : ........................................................
5
8) HIV/AIDS : ........................................................
9) Cacat Fisik/Psikologis : ........................................................
10) Rawat Inap/Operasi : ........................................................
c. Riwayat Kesehatan Keluarga

1) Jantung : ........................................................
2) Hipertensi : ........................................................
3) Asma : ........................................................
4) Tubercolusis : ........................................................
5) Ginjal : ........................................................
7) Malaria : ........................................................
8) HIV/AIDS : ........................................................
10) Gemeli : ........................................................
d. Riwayat Penyakit Keturunan : ........................................................

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5. Data Kebiasaan Sehari-hari
6
Sebelum Hamil Selama Hamil Keluhan
Pola Nutrisi
Makan
Jenis
Frekuensi
Pantangan
Minum
Jenis
Frekuensi
Pola Eliminasi
BAB
Konsistensi
:
Warna
:
Frekuensi
:
BAK
Warna
:
Bau
:
Frekuensi
:
Aktivitas Sehari-hari
Jenis
Pola Istirahat
Tidur siang
Tidur malam
Personal Hygiene
Mandi
7
Gosok gigi
::
Ganti pakaian
Keramas
Pola Seksual
:
:
:
Kebiasaan Negatif
Merokok
Narkoba
Alcohol
Minum jamu
6. Data Psikososiospiritual
a. Hubungan dengan keluarga : ........................................................
b. Pengambil keputusan : ........................................................
c. Tinggal dengan : ........................................................
d. Hewan peliharaan : ........................................................
e. Cara memasak sayur : ........................................................
f. Hubungan dengan masyarakat : ........................................................
g. Kegiatan ibadah : ........................................................
h. Psikologis : ........................................................
7. Pengetahuan Ibu tentang kehamilan : .................................................

......................................................................................................................
......................................................................................................................
B. Data Objektif
1. HPL : ........................................................
2. Pemeriksaan Umum : ........................................................
a. Keadaan Umum : ........................................................
b. Kesadaran : ........................................................
c. Tanda-tanda Vital : ........................................................
1) Tekanan darah : ........................................................
2) Suhu : ........................................................
3) Respirasi : ........................................................
4) Nadi : ........................................................
8
d. BB sebelum hamil :…........... BB sekarang :........... TB:…......... LILA:...............
3. Pemeriksaan Fisik
a. Muka : ...............................................................
b. Rambut : ...............................................................
c. Mata : ...............................................................
d. Hidung : ...............................................................
e. Telinga : ...............................................................
f. Mulut : ...............................................................
g. Leher : ...............................................................
h. Dada : ...............................................................
i. Payudara : ...............................................................
j. Ketiak : ...............................................................
k. Abdomen : ...............................................................
l. Ekstrimitas Atas : ...............................................................
m. Ekstrimitas Bawah : ..............................................................
n. Genetalia : ...............................................................
o. Anus : ...............................................................
4. Pemeriksaan Khusus
a. Inspeksi
1) Muka : ...............................................................
2) Payudara : ...............................................................
3) Abdomen : ...............................................................
4) Genetalia : ...............................................................
(Pengeluaran per Vaginam : lendir darah, air ketuban, darah dll)
b. Palpasi
1) Payudara : ...............................................................
2) Abdomen :
a) Leopold I : ...............................................................
..............................................................................................
..............................................................................................
..............................................................................................
b) Leopold II : ...............................................................
..............................................................................................
..............................................................................................
..............................................................................................
c) Leopold III : ...............................................................
..............................................................................................
9
..............................................................................................
d) Leopold IV : ...............................................................
..............................................................................................
..............................................................................................
e) Tinggi Fundus Uteri : ........................................................
f) Tafsiran Berat Janin : ……….. gram
c. Auskultasi
1) DJJ : Frekuensi :…………x/menit
2) Punctum maximum : ......................................................
d. Perkusi : Reflek Patella : .....................................................
e. Pemeriksaan Panggul Luar : ......................................................
C. Data Penunjang
1. Pemeriksaan Lab : ...............................................................
2. Pemeriksaan USG : ...............................................................
3. Pemeriksaan Lain : ...............................................................
II. INTERPRETASI DATA

Tanggal : ................................................. Jam : .....................................
A. Diagnosa Kebidanan
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B. Dasar
1. Dasar Subjektif : ........................................................................................
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2. Dasar Objektif : .........................................................................................

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C. Masalah
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D. Kebutuhan
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III. DIAGNOSA POTENSIAL

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IV. ANTISIPASI TINDAKAN SEGERA

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V. RENCANA TINDAKAN
Tanggal : ................................................. Jam : .....................................
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VI. IMPLEMENTASI
Tanggal : ................................................. Jam : .....................................
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VII. EVALUASI
Tanggal : ................................................. Jam : .....................................
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PEMBIMBING LAHAN YANG MEMBUAT LAPORAN
(...........................................)
(.............................................)
NIM.
Mengetahui,
PEMBIMBING AKADEMIK
13
(........................................)
14
ASUHAN KEBIDANAN IBU BERSALIN
Tanggal Masuk : .......................................... Jam : ............................

No. Register : .........................................................................................
.
I. PENGKAJIAN
Tanggal ................................... Jam ..........................................
A. Data Subjektif
1. Identitas Pasien
ISTRI SUAMI
1) Nama : ........................................ ..
2) Umur : ........................................ .................................
3) Pendidikan : ........................................ .................................
4) Pekerjaan : ........................................ .................................
5) Alamat : ................................................................................
2. Keluhan Utama pada Waktu Datang : ..................................................................

.................................................................................................................................
.................................................................................................................................
3. Tanda – Tanda Persalinan
a. Kontraksi sejak tanggal : ............................ Jam .....................................

1) Frekuensi : .................................
2) Lama : .................................
3) Lokasi Nyeri : .................................
b. Pengeluaran per Vaginam :
15
1) Lendir Darah : ........................... Tanggal/Jam...........................
2) Air Ketuban : ............................ Tanggal/Jam...........................
4. Data Kebidanan
1) Menarche : ................................................................................
2) Siklus : ................................................................................
3) Lama : ................................................................................
4) Banyak Darah : ................................................................................
5) Bau : ................................................................................
6) Warna : ................................................................................
7) Konsistensi : ................................................................................
8) Dismenorhoe : ................................................................................
9) Flour Albus : ................................................................................
Hamil Tahun Umur Jenis Penolong Tempat Komplikasi JK/BB /PB Kead Laktasi Penyulit
ke- lahir Khmln Persalinan Skrng Nifas
16
c. Riwayat Kehamilan Sekarang
1) G...P....A... :
2) HPHT :
3) HPL :
4) Umur Kehamilan :
5) Tempat ANC :
6) ANC Teratur / Tidak : ........... kali (TM I : x, ; II: x ; III: )
7) Keluhan :
a) TM I :
b) TM II :
c) TM III :
8) Gerakan janin yang pertama kali bulan, gerakan janin sekarang (aktif/jarang)
9) Imunisasi :
a) TT I : tanggal ........................................
b) TT II : tanggal ........................................
c) TT III : tanggal ........................................
d) TT IV : tanggal ........................................
e) TT V : tanggal ........................................
10) Obat-obatan yang dikonsumsi :
11) Penyuluhan yang pernah didapat :
12) Kebiasaan Negatif Ibu Selama Hamil
...................................................................................................
...................................................................................................
d. Riwayat KB
17
1) Jenis alkon :
2) Lama penggunaan :
3) Efek samping :
1) Nikah : kali
2) Umur Istri : tahun
3) Umur Suami : tahun
4) Lama pernikahan : tahun
a. Data Kesehatan Sekarang
1) Jantung :
2) Hipertensi :
3) Asma :
4) Tubercolusis : tidak ada
5) Ginjal : tidak ada
6) Diabetes Militus : tidak ada
7) Malaria : tidak ada
8) HIV/AIDS : tidak ada
9) Cacat Fisik/Psikologis : tidak ada
1) Jantung : tidak ada
2) Hipertensi : tidak ada
3) Asma : tidak ada
18
10) Rawat Inap/Operasi : tidak ada
1) Jantung : tidak ada
2) Hipertensi : tidak ada
3) Asma : tidak ada
10) Gemeli : tidak ada
d. Riwayat Penyakit Keturunan : ibu mengatakan tidak ada penyakit keturunan
19
Sebelum Hamil Selama Hamil Keluhan
Pola Nutrisi
Makan
Jenis Nasi,lauk,sayur
Frekuensi 3x/hari
Pantangan Tidak ada
Minum
Jenis Susu,air putih
Frekuensi Sering
Pola Eliminasi
BAB
Konsistensi
:
Warna
:
Frekuensi
:
BAK
Warna
:
Bau
:
Frekuensi
:
Jenis
Pola Istirahat
Tidur siang
Tidur malam
Personal Hygiene
Mandi
Gosok gigi
::
Ganti pakaian
Keramas
Pola Seksual
:
:
20
:
Kebiasaan Negatif
Merokok
Narkoba
Alcohol
Minum jamu
a. Hubungan dengan keluarga : baik
b. Pengambil keputusan : suami
c. Tinggal dengan : orang tua
d. Hewan peliharaan : ayam
e. Cara memasak sayur : tergantung sayur yang di masak
f. Hubungan dengan masyarakat : baik
g. Kegiatan ibadah : baik
h. Psikologis : baik
8. Pengetahuan Ibu tentang Persalinan :
A. Data Objektif
1. Pemeriksaan Umum : ..................................................................

a. Keadaan Umum : baik
b. Kesadaran : composmetis
c. Tanda-tanda Vital :
1) Tekanan darah : 120/70
2) Suhu : 36 c
3) Respirasi : 24x/mnt
4) Nadi : 83x/mnt
d. BB sebelum hamil : 50 BB sekarang : 55 TB: 150 LILA:24
21
a. Muka : tidak ada edema
b. Rambut : bersih,rontok,panjang lurus
c. Mata :
d. Hidung : ...............................................................
e. Telinga : ...............................................................
f. Mulut : ...............................................................
g. Leher : ...............................................................
h. Dada : ...............................................................
i. Payudara : ...............................................................
j. Ketiak : ...............................................................
k. Abdomen : ...............................................................
n. Genetalia : ...............................................................
o. Anus : ...............................................................
a. Inspeksi
1) Muka : ...............................................................
2) Payudara : ...............................................................
3) Abdomen : ...............................................................
4) Genetalia : ...............................................................
b. Palpasi
1) Payudara : ...............................................................
2) Abdomen : ...............................................................
a) Leopold I : TFU 3jari di bawah Px bagian fundus uteri

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b) Leopold II : ...............................................................
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c) Leopold III : ...............................................................
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d) Leopold IV : ...............................................................
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..............................................................................................
e) Tinggi Fundus Uteri : ........................................................

f) Tafsiran Berat Janin : ……….. gram
c. Auskultasi
1) DJJ : Frekuensi :…………x/menit
2) Punctum maximum : ......................................................
......................................................
d.Perkusi : Reflek Patella : .....................................................
......................................................
e. Pemeriksaan Panggul Luar : ......................................................
f. VT : ...................................................
V/U……………………, dinding vagina………….porsio………,effisement……….
pembukaan……, selaput ketuban………............presentasi…………………………,
penurunan kepala di Hogde ……, UUK jam ………… , STLD + / -
g. Pemeriksaan Panggul Luar (bila perlu)
............................................................................................................
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B. Data Penunjang
1. Pemeriksaan Lab : ...............................................................
2. Pemeriksaan USG : ...............................................................
23
Tanggal : 18 desember 2015 Jam: 09.55 wib

Ny n G2P2A1 umur 23 tahun Uk 39 minggu,janin hidup,ketiak memanjang
B. Dasar
1. Dasar Subjektif : ibu mengatakan berusia 23 tahun,
Ibu mengatakan ini adalah kehamilan kedua dan sudah
pernah keguguran .
2. Dasar Objektif : KU : baik,TD: 120/70, N:83x/mnt ,R : 24x/mnt, S:36 c
C. Masalah
Tidak ada
D. Kebutuhan : pemenuhan nutrisi saat persalinan,posissi yang nyaman bagi ibu
DIAGNOSA POTENSIAL
Tidak ada
ANTISIPASI TINDAKAN SEGERA
Tidak ada
III. RENCANA TINDAKAN
Tanggal : 18 Desember 2015 Jam: 10.15 wib
1.Ukur KU,VT setiap 4jam,his dan Djj setiap 15 mnt,kemajuan persalinan setiap 4 jam.
2.Lakukan kolaborasi
3.Kosongkan kandung kemih
4.Beri suport mental kepda ibu saat menghadapi persalinan
5.Beritahu ibu tentang hasil pemeriksaan dan keadaan janinnya
6.Anjurkan ibu teknik relaksasi,miring kiri
7.Siapkan partus sest dan pakaian ibu serta pakaian bayi
8.Dokumentasi
24
IV. IMPLEMENTASI
Tanggal : 18 Desember 2015
1.Pukul: 10.20 wib :mengukur Ku,VT setiap 4 jam his dan Djj setiap 15 mnt,Kemajuan
persalianan setiaap 4jam
2.Pukul : 10.30 Melakukan kolaborasi dengan bidan
3.Pukul : 10.34 Mengosongkan kandung kemih
4.Pukul :10.37 Memberi suport mental kepda ibu saat menghadapi persalinan
5.Pukul :10.40 WIB Memberitahu ibu tentang hasil pemeriksaan dan keadaan janinnya
6.Pukul :10.45 WIB Menganjurkan ibu teknik relaksasi,miring kiri
7.Pukul :10.55 WIB Menyiapkan partus sest dan pakaian ibu serta pakaian bayi
8.Pukul :11.05WIB Mendokumentasikan
EVALUASI
Tanggal : 18 Desember 2015 Jam: 11.15s
1.Ibu mengetahui keadaan janinya baik
2.Bidan melakukan kolaborasi tindakan
3.ibu sudah merasa tenang,bayinya lahir selamat nantinya
4.Hasil pemeriksaan janin ibu baik
7.ibu sudah melakukan teknik relaksasi miring kiri
8.Partus set dan pakaian ibu serta pakaian bayi sudah disiapkan
9.Dokumentasi tindakan
(...........................................) (.............................................)
NIM.
Mengetahui,
PEMBIMBING AKADEMIK
(........................................)
LEMBAR OBSERVASI KALA I FASE LATEN
25
Tanggal & Jam Datang : ..............................................................................................
Nama : ..............................................................................................
Umur : ..............................................................................................
Alamat : ..............................................................................................
PEMERIKSAAN
NO TANGGAL JAM DJJ KONTRAKSI HIS VT TTV
(x/menit (x/10 menit)
26
Makan : Jam ……….. ( …… Porsi ) Penolong
Minum : Jam ………. ( …… Porsi )
( ……………………………………………… )
27
28
ASUHAN KEBIDANAN IBU NIFAS

........................................................................................................
........................................................................................................
Tanggal Pengkajian : .......................................... Jam : ............................
No. Register : .........................................................................................
.
I. PENGKAJIAN
A. Data Subjektif
1. Identitas Pasien
ISTRI SUAMI
1) Nama : ........................................ .................................
2) Umur : ........................................ .................................
3) Pendidikan : ........................................ .................................
4) Pekerjaan : ........................................ .................................
5) Alamat : ................................................................................
2. Keluhan Utama pada Waktu Datang : ................................................................

...............................................................................................................................
...............................................................................................................................
3. Data Kebidanan
1) Menarche : ................................................................................
2) Siklus : ................................................................................
3) Lama : ................................................................................
4) Banyak Darah : ................................................................................
5) Bau : ................................................................................
6) Warna : ................................................................................
7) Konsistensi : ................................................................................
8) Dismenorhoe : ................................................................................
9) Flour Albus :
29
Hamil Tahun Umur Jenis Penolong Tempat Kompli JK/BB /PB Kead Laktasi Penyulit
ke- lahir Khmln Persali kasi Skrng Nifas
nan
c. Riwayat Persalinan dan Nifas

1) Tanggal Persalinan ……. Jam …...
2) Jenis Persalinan :
3) Bayi Lahir…PB…….BB……...LD……..LK……..AS……………
4) Lama Persalinan
a) Kala I : ……......jam, Jumlah Perdarahan ……..cc
b) Kala II : ……......jam, Jumlah Perdarahan ……..cc
c) KalaIII : ……......jam, Jumlah Perdarahan ……..cc
d) KalaIV : …….. ...jam, Jumlah Perdarahan ……..cc
5) Total Lama Persalinan : …….....jam, Total Perdarahan………...cc
6) Keadaan Plasenta : .............................................................
7) Penyulit Persalinan : .............................................................
8) Jenis lochea : .............................................................
d. Riwayat KB
1) Jenis alkon : .............................................................
2) Lama penggunaan : .............................................................
3) Efek samping : .............................................................
1) Nikah :….... kali
2) Umur Istri :….... tahun
3) Umur Suami :.…... tahun
4) Lama pernikahan : ........tahun
30
a. Riwayat Kesehatan Sekarang
1) Jantung : ........................................................
2) Hipertensi : ........................................................
3) Asma : ........................................................
4) Tubercolusis : ........................................................
5) Ginjal : ........................................................
7) Malaria : ........................................................
8) HIV/AIDS : ........................................................
........................................................
31
1) Jantung : ........................................................
2) Hipertensi : ........................................................
3) Asma : ........................................................
4) Tubercolusis : ........................................................
5) Ginjal : ........................................................
7) Malaria : ........................................................
8) HIV/AIDS : ........................................................
32
Sebelum nifas Selama Nifas Keluhan
Pola Nutrisi
Makan
Jenis
Frekuensi
Pantangan
Alergi
Minum
Jenis
Frekuensi
Pola Eliminasi
BAB
Konsistensi
:
Warna
:
Frekuensi
:
BAK
Warna
:
Bau
:
Frekuensi
:
Aktivitas
Pola Istirahat
Tidur siang
Tidur malam
:
:
Personal Hygiene
Mandi
Gosok gigi
:
Ganti pakaian
Keramas
:
33
Kebiasaan
Negatif
Merokok
Narkoba
Alcohol
Minum jamu
............................
i. Hubungan dengan keluarga : ........................................................
j. Pengambil keputusan : ........................................................
k. Tinggal dengan : ........................................................
l. Hewan peliharaan : ........................................................
m. Cara memasak sayur : ........................................................
n. Hubungan dengan masyarakat : ........................................................
o. Kegiatan ibadah : ........................................................
p. Psikologis : ........................................................
7. Pengetahuan Ibu tentang Persalinan : .................................................
......................................................................................................................
......................................................................................................................
B. Data Objektif
a. Keadaan Umum : ..................................................................
b. Kesadaran : ..................................................................
c. Tanda-tanda Vital : ..................................................................
1) Tekanan darah : ..................................................................
2) Suhu : ..................................................................
3) Respirasi : ..................................................................
4) Nadi : ..................................................................
a. Muka : ...............................................................
b. Rambut : ...............................................................
c. Mata : ...............................................................
d. Hidung : ...............................................................
34
e. Telinga : ...............................................................
f. Mulut : ...............................................................
g. Leher : ...............................................................
h. Dada : ...............................................................
i. Payudara : ...............................................................
j. Ketiak : ...............................................................
k. Abdomen : ...............................................................
n. Genetalia : ...............................................................
o. Anus : ...............................................................
a. Palpasi
1) Payudara : ...............................................................
Benjolan Tumor : ...............................................................
2) Abdomen :
a) TFU :
b) Kontraksi : ...............................................................
b. Perkusi :
a) Reflek Patella : ...............................................................
C. Data Penunjang
1. Pemeriksaan Lab : ...............................................................
2. Pemeriksaan USG : ...............................................................
35
Tanggal : ................................................. Jam : .....................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
B. Dasar
a. Dasar Subjektif :
.............................................................................................................................
b. Dasar Objektif :
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
C. Masalah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
D. Kebutuhan
....................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
V. RENCANA TINDAKAN
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
36
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
VI. IMPLEMENTASI
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
37
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
VII. EVALUASI
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
(...........................................) (.............................................)
NIM.
Mengetahui,
PEMBIMBING AKADEMIK
38
(........................................)

ASUHAN KEBIDANAN BAYI BARU LAHIR

................................................................................................
......................................................................................................
Tanggal Pengkajian : ..................................................................................

Jam : ..................................................................................
Tempat Pengkajian : ..................................................................................
No. Register : ..................................................................................
I. PENGKAJIAN
A. Data Subjektif
1. Identitas
a. Identitas Pasien
1) Nama bayi : ...........................................................
2) Umur bayi : ...........................................................
3) Tanggal/jam lahir : ...........................................................
4) Jenis Kelamin : ...........................................................
5) BB/PB : ...........................................................
6) LILA/LD/LK : ...........................................................
b. Identitas Penanggung Jawab

1) Nama Ayah/Ibu : ...........................................................
2) Umur Ayah/Ibu : ...........................................................
3) Agama : ...........................................................
4) Suku/Bangsa : ...........................................................
39
5) Pendidikan : ...........................................................
6) Pekerjaan : ...........................................................
7) Alamat : ...........................................................
40
2. Riwayat Kehamilan Ibu
a. Pemeriksaan ANC
1) G.........P....... A .........
2) ANC: di ................, teratur/tidak, ....... x (TMI.......x, TMII.......x,
TMIII.........x)
3) Keluhan
a) TM I : ...........................................................
b) TM II : ...........................................................
c) TM : ...........................................................
4) HPHT : ...........................................................
5) HPL : ...........................................................
6) Imunisasi
a) TT I : tanggal .........................................
b) TT II : tanggal ..........................................
c) TT III : tanggal ..........................................
d) TT IV : tanggal ..........................................
e) TT V : tanggal ..........................................
7) Kenaikan BB selama hamil : ........... kg
8) Riwayat penyakit kehamilan
a) Perdarahan : ...........................................................
b) Eklamsi : ...........................................................
c) Lainnya : ...........................................................
9) Kebiasan ibu waktu hamil

a) Makanan : ...........................................................
b) Obat-obatan/jamu : ...........................................................
c) Merokok : ...........................................................
d) Lainnya……………………..
3. Riwayat Persalinan
a. Tanggal Lahir : ............................ Jam : .......................
b. Tempat : ............................
c. Penolong : ............................
d. Jenis Persalinan : ............................
e. Lama Persalinan : ............................
41
f. KK Pecah : ............................ Jam : .......................
Warna : .............. Jumlah : .....................
g. Penyulit/komplikasi : ......................................................
h. Penggunaan Obat Selama Persalinan : ............................................
B. Data Objektif
a. Usaha Nafas dengan Bantuan/Tanpa Bantuan :
b. APGAR Score
APGAR 1 Menit 5 Menit 10 Menit

Appearance
Pulse Rate
Grimace
Activity
Respiration
Score
c. Kebutuhan Resusitasi : ……….Jenis……….Lama……..
d. Trauma Lahir
1) Cepal hematoma
2) Caput suksedaneum
3) Lainnya....................
2. Pemeriksaan Umum
a. Keadaan Umum : ...........................................................
b. Kesadaran : ...........................................................
c. Tanda-tanda Vital
1) Nadi : ...........................................................
2) Pernafasan : ...........................................................
3) Suhu : ...........................................................
d. Antropometri
1) BB : ...........................................................
2) PB : ...........................................................
42
3) LK : ...........................................................
4) LD : ...........................................................
5) LILA : ...........................................................
3. Pemeriksaan Fisik/ Status Present
a. Kepala
1) Ubun-ubun : ...........................................................
2) Sutura Molase : ...........................................................
b. Muka : ...........................................................
c. Mata : ...........................................................
d. Hidung : ...........................................................
e. Telinga : ...........................................................
f. Mulut : ...........................................................
g. Leher : ...........................................................
h. Dada
1) Bentuk : ...........................................................
2) Putting Susu : ...........................................................
3) Bunyi Nafas : ...........................................................
i. Bahu, Lengan dan Tangan : ...........................................................
j. Abdomen/Perut
1) Bentuk : ...........................................................
2) Penonjolan sekitar tali pusat pada saat menangis .....................
3) Perdarahan tali pusat : ...........................................................
4) Benjolan : ...........................................................
k. Genetalia/Alat Kelamin :
1) Laki-laki
a) Testis : turun / tidak turun dalam skrotum
43
b) Penis Berlubang : ya / tidak
c) Letak : ...........................................................
2) Perempuan
a) Vagina : terbentuk / tidak terbentuk
b) Uretra : berlubang / tidak berlubang
c) Labia mayora : terbentuk / tidak terbentuk
d) Labia minora : terbentuk / tidak terbentuk
l. Ekstrimitas Atas : ...........................................................
m. Ekstrimitas Bawah : ...........................................................
n. Punggung/Spina : ...........................................................
o. Kulit
1) Verniks : ...........................................................
2) Warna : ...........................................................
3) Pembengkakan : ...........................................................
4) Tanda-tanda Lahir : ...........................................................
p. Reflek Fisiologis
1) Reflek Morro : ...........................................................
2) Reflek Rooting : ...........................................................
3) Reflek Suckling : ...........................................................
4) Reflek Grassping : ...........................................................
5) Reflek Tonik Neck : ...........................................................
6) Reflek Babynski : ...........................................................
q. Eliminasi
1) Urin : ...........................................................
2) Mekoneum : ...........................................................
C. Data Penunjang
1. Pemeriksaan Lab : ...........................................................
2. Pemeriksaan USG : ...........................................................
3. Pemeriksaan Lain : ...........................................................
Tanggal : ................................................. Jam : .....................................
....................................................................................................................................
44
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
B. Dasar
1. Dasar Subjektif : ....................................................................................
.............................................................................................................................
2. Dasar Objektif :
.............................................................................................................................
C. Masalah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
D. Kebutuhan
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................

...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
V. RENCANA TINDAKAN
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
VI. IMPLEMENTASI
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
45
...........................................................................................................................................
VII. EVALUASI
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
(...........................................) (.............................................)
NIM.
Mengetahui,
PEMBIMBING AKADEMIK
(........................................)

46
ASUHAN KEBIDANAN PADA BALITA
........................................................................................
........................................................................................
Tanggal Pengkajian : ..................................................................................

Jam : ..................................................................................
Tempat Pengkajian : ..................................................................................
No. Register : ..................................................................................
I. PENGKAJIAN
A. Data Subjektif
1. Identitas
a. Identitas Anak
1) Nama : ..................................................................
2) Umur : ..................................................................
3) Jenis kelamin : ..................................................................
4) Anak nomor : ..................................................................
5) Sekolah : ..................................................................
b. Identitas orangtua
1) Nama : ..................................................................
2) Agama : ..................................................................
3) Pendidikan : ..................................................................
4) Pekerjaan : ..................................................................
5) Jumlah anak : ..................................................................
6) Status perkawinan : kawin/tak kawin/janda/duda
7) Alamat : ..................................................................
2. Keluhan Utama pada Waktu Datang

........................................................................................................................
........................................................................................................................
........................................................................................................................
3. Data Pertumbuhan dan

Perkembangan
a. Pertumbuhan
1) Umur kehamilan (lama mengandung si anak) : ............................
2) Persalinan ditolong oleh : ............................
47
3) BB/PB lahir : ...........................................................................
4) Kelainan : ...........................................................................
5) Anak mendapat ASI sejak umur : ......... bulan
6) Anak mendapat PASI sejak umur : ......... bulan, jenis :
7) Anak mendapat makanan tambahan sejak : ..... bulan, jenis :
8) Riwayat imunisasi
No Usia Imunisasi yang diberikan Tanggal Pemberian

1. 0 Bulan Hepatitis B 0
2. 1 Bulan BCG, Polio 1
3. 2 Bulan DPT-HB-Hib 1, Polio 2
6. 9 Bulan Campak
7. 18 Bulan DPT-HB-Hib
8. 24 Bulan Campak
b. Perkembangan
1) Umur membalik badan : .............................................................
2) Umur berdiri : .............................................................
3) Umur mengoceh : .............................................................
4) Umur duduk : .............................................................
5) Umur berjalan : .............................................................
6) Umur berbicara : .............................................................
4. Data kebutuhan Dasar

Jenis Keterangan Keluhan
Nutrisi
Makan
Makanan yang disukai
Makanan yang tidak disukai
Frekuensi
Porsi
Jenis
Pantangan
48
Waktu pemberian makan
Minum
Minuman yang disukai
Minuman yang tidak disukai
Frekuensi
Porsi
Jenis
Pantangan
Eliminasi
BAK
Frekuensi
Warna Urine
BAB
Frekuensi Konsistensi
Warna
Istirahat
Tidur siang Jam
Jam
Tidur malam
Hal-hal yang mempermudah tidur
Hal-hal yang mempernudah
bangun
Personal Hygiene
Mandi
Sikat gigi
Keramas
Ganti pakaian
Potong kuku
Potong rambut
Aktivitas bermain
Teman bermain
Jenis permainan
Waktu bermain
a. Riwayat Penyakit Sekarang
...................................................................................................................
b. Riwayat Penyakit Dahulu
...................................................................................................................
c. Riwayat Penyakit Keluarga
...................................................................................................................
B. Data Objektif
1. Pemeriksaan Umum
a. Keadaan Umum : ........................................
b. Kesadaran :
49
c. Vital Sign : ........................................
1) Nadi : ............. X / menit

2) Pernapasan : .............. X / menit
3) Suhu : .............. 0C
d. BB : kg
e. PB : cm
f. LiLa : cm
a. Wajah :
- Warna : .............................................................................
.............................................................................
- Oedema : .............................................................................
.............................................................................
.............................................................................
b. Rambut :
- Warna : .............................................................................
- Pertumbuhan : .............................................................................
- Keadaan : .............................................................................
c. Mata :
- Conjungtiva : .............................................................................
.............................................................................
c. Mata :
- Sklera : .............................................................................
- Sekret : .............................................................................
d. Hidung :
-Sekret : .............................................................................
.............................................................................
-Keadaan : .............................................................................
.............................................................................
-Lesi : .............................................................................
.............................................................................
- Polip : .............................................................................
.............................................................................
50
e. Mulut :
- Keadaan : .............................................................................
- Lidah : .............................................................................
- Gigi : .............................................................................
- Gusi : .............................................................................
f. Leher :
- Kelenjar Tyriod : .............................................................................
- Kelenjar Parotis : .............................................................................
g. Dada :
- Bentuk : .............................................................................
- Payudara : .............................................................................
- Tipe pernapasan : .............................................................................
- KGB axilla : .............................................................................
h. Abdomen : .............................................................................
- Bentuk : .............................................................................
- Bekas luka operasi : .............................................................................
- Kembung : .............................................................................
i. Ekstrimitas : .............................................................................
- Oedeme : .............................................................................
- Kelainan : .............................................................................
j. Genetalia : .............................................................................
- Oedem : .............................................................................
- Sekret : .............................................................................
- Kelainan : .............................................................................
k. Anus : .............................................................................
C. Data Penunjang
1. Pemeriksaan Laboratorium : ......................................................................
2. Pemeriksaan USG : ......................................................................
3. Pemeriksaan Lain : ......................................................................
D. Pengobatan yang telah didapat : ......................................................................

51
......................................................................

Tanggal : ................................................. Jam : .....................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
B. Dasar
1. Dasar Subjektif : ....................................................................................
.............................................................................................................................
2. Dasar Objektif : .....................................................................................
.............................................................................................................................
.............................................................................................................................
C. Masalah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
52
D. Kebutuhan
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
IV. DIAGNOSA POTENSIAL

...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
V. ANTISIPASI TINDAKAN SEGERA

...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
VI. RENCANA TINDAKAN

Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
VII. IMPLEMENTASI
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
53
VIII. EVALUASI
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
(...........................................) (.............................................)
NIM.
Mengetahui,
PEMBIMBING AKADEMIK
(........................................)
54
ASUHAN KEBIDANAN KELUARGA BERENCANA

..........................................................................................
..........................................................................................
No. Register : .........................................................................................
.
I. PENGKAJIAN
B. Data Subjektif
1. Identitas Pasien
ISTRI SUAMI
1) Nama : .......................................... .................................
2) Umur : ........................................ .................................
3) Pendidikan : ........................................ .................................
4) Pekerjaan : ........................................ .................................
5) Alamat : ................................................................................

...............................................................................................................................
...............................................................................................................................
3. Data Kebidanan
1) Menarche : ................................................................................
2) Siklus : ................................................................................
3) Lama : ................................................................................
4) Banyak Darah : ................................................................................
5) Bau : ................................................................................
6) Warna : ................................................................................
7) Konsistensi : ................................................................................
8) Dismenorhoe : ................................................................................
9) Flour Albus : ................................................................................
55
Hamil ke- Tahun lahir Umur Khmln Jenis Persalinan Penolong Tempat Komplikasi JK/BB /PB Kead Skrng Laktasi Penyulit
Nifas
56
c. Riwayat KB
1) Jenis alkon : .............................................................
2) Lama penggunaan : .............................................................
3) Efek samping : .............................................................
4) Cara Penanganan : .............................................................
5) Alasan Berhenti : .............................................................
6) Rencana Selanjutnya : .............................................................
d. Status Perkawinan
1) Nikah : ….... kali
2) Umur Istri : ….... tahun
3) Umur Suami : .…... tahun
4) Lama pernikahan : ........ tahun
1) Jantung : ........................................................
2) Hipertensi : ........................................................
3) Asma : ........................................................
4) Tubercolusis : ........................................................
5) Ginjal : ........................................................
7) Malaria : ........................................................
8) HIV/AIDS : ........................................................
57
1) Jantung : ........................................................
2) Hipertensi : ........................................................
3) Asma : ........................................................
4) Tubercolusis : ........................................................
5) Ginjal : ........................................................
7) Malaria : ........................................................
8) HIV/AIDS : ........................................................
1) Jantung : ........................................................
2) Hipertensi : ........................................................
3) Asma : ........................................................
4) Tubercolusis : ........................................................
5) Ginjal : ........................................................
7) Malaria : ........................................................
8) HIV/AIDS : ........................................................
d. Riwayat Penyakit Keturunan: ........................................................

........................................................
58
Sekarang Keluhan
Pola Nutrisi
Makan
Jenis
Frekuensi
Pantangan
Alergi
Minum
Jenis
Frekuensi
Pola Eliminasi
BAB
Konsistensi
:
Warna
:
Frekuensi
:
BAK
Warna
:
Bau
:
Frekuensi
:
Jenis
Pola Istirahat
Tidur siang
Tidur malam
:
:
Personal Hygiene
Mandi
Gosok gigi
:
Ganti pakaian
Keramas
:
Pola Seksual
:
Frekuensi
59
:
:
Kebiasaan Negatif
Merokok
Narkoba
Alcohol
Minum jamu
............................
c. Tinggal dengan : ........................................................
h. Psikologis : ........................................................
7. Pengetahuan Ibu tentang KB : ........................................................

......................................................................................................................
B. Data Objektif
a. Keadaan Umum : ..................................................................
b. Kesadaran : ..................................................................
1) Tekanan darah : ..................................................................
2) Suhu : ..................................................................
3) Respirasi : ..................................................................
4) Nadi : ..................................................................
d. BB / TB / LILA : ..................................................................
a. Muka : ...............................................................
b. Rambut : ...............................................................
c. Mata : ...............................................................
d. Hidung : ...............................................................
e. Telinga : ...............................................................
f. Mulut : ...............................................................
60
g. Leher : ...............................................................
h. Dada : ...............................................................
i. Payudara : ...............................................................
j. Ketiak : ...............................................................
k. Abdomen : ...............................................................
n. Genetalia : ...............................................................
o. Anus : ...............................................................
3. Pemeriksaan Khusus (sesuai dengan jenis Alkon yang digunakan pasien)
a. Palpasi
.........................................................................................................
.........................................................................................................
b. Inspeksi
.......................................................................................................
.......................................................................................................
c. Inspeculo
............................................................................................................
............................................................................................................
C. Data Penunjang
1. Pemeriksaan Lab : ...............................................................
2. Pemeriksaan USG : ...............................................................

Tanggal : ................................................. Jam : .....................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
B. Dasar
1. Dasar Subjektif : ....................................................................................
.............................................................................................................................
.............................................................................................................................
2. Dasar Objektif : .....................................................................................
.............................................................................................................................
61
.............................................................................................................................
C. Masalah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
D. Kebutuhan
....................................................................................................................................
....................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
V. RENCANA TINDAKAN
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
VI. IMPLEMENTASI
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
VII. EVALUASI
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
(...........................................) (.............................................)
NIM.
62
Mengetahui,
PEMBIMBING AKADEMIK
(........................................)

ASUHAN KEBIDANAN GANGGUAN REPRODUKSI

..........................................................................................
..........................................................................................
No. Register : .........................................................................................
.
II. PENGKAJIAN
A. Data Subjektif
1. Identitas Pasien
ISTRI SUAMI
1) Nama : .......................................... .................................
2) Umur : ........................................ .................................
3) Pendidikan : ........................................ .................................
4) Pekerjaan : ........................................ .................................
5) Alamat : ................................................................................

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
3. Data Kebidanan
1) Menarche : ................................................................................
2) Siklus : ................................................................................
3) Lama : ................................................................................
4) Banyak Darah : ................................................................................
63
5) Bau : ................................................................................
6) Warna : ................................................................................
7) Konsistensi : ................................................................................
8) Dismenorhoe : ................................................................................
9) Flour Albus : ................................................................................
64
Hamil ke- Tahun lahir Umur Khmln Jenis Persalinan Penolong Tempat Komplikasi JK/BB /PB Kead Skrng Laktasi Penyulit
Nifas
65
c. Riwayat KB
1) Jenis alkon : .............................................................
2) Lama penggunaan : .............................................................
3) Efek samping : .............................................................
4) Cara Penanganan : .............................................................
5) Alasan Berhenti : .............................................................
6) Rencana Selanjutnya : .............................................................
d. Status Perkawinan
1) Nikah : ….... kali
2) Umur Istri : ….... tahun
3) Umur Suami : .…... tahun
4) Lama pernikahan : ........ tahun
1) Jantung : ........................................................
2) Hipertensi : ........................................................
3) Asma : ........................................................
4) Tubercolusis : ........................................................
5) Ginjal : ........................................................
7) Malaria : ........................................................
8) HIV/AIDS : ........................................................
66
1) Jantung : ........................................................
2) Hipertensi : ........................................................
3) Asma : ........................................................
4) Tubercolusis : ........................................................
5) Ginjal : ........................................................
7) Malaria : ........................................................
8) HIV/AIDS : ........................................................
1) Jantung : ........................................................
2) Hipertensi : ........................................................
3) Asma : ........................................................
4) Tubercolusis : ........................................................
5) Ginjal : ........................................................
7) Malaria : ........................................................
8) HIV/AIDS : ........................................................
d. Riwayat Penyakit Keturunan: ........................................................

........................................................
67
Sekarang Keluhan
Pola Nutrisi
Makan
Jenis
Frekuensi
Pantangan
Alergi
Minum
Jenis
Frekuensi
Pola Eliminasi
BAB
Konsistensi
:
Warna
:
Frekuensi
:
BAK
Warna
:
Bau
:
Frekuensi
:
Jenis
Pola Istirahat
Tidur siang
Tidur malam
:
:
Personal Hygiene
Mandi
Gosok gigi
:
Ganti pakaian
Keramas
:
Pola Seksual
:
Frekuensi
68
:
:
Kebiasaan Negatif
Merokok
Narkoba
Alcohol
Minum jamu
............................
c. Tinggal dengan : ........................................................
h. Psikologis : ........................................................
7. Pengetahuan Ibu tentang KB : ........................................................

......................................................................................................................
B. Data Objektif
a. Keadaan Umum : ..................................................................
b. Kesadaran : ..................................................................
1) Tekanan darah : ..................................................................
2) Suhu : ..................................................................
3) Respirasi : ..................................................................
4) Nadi : ..................................................................
d. BB / TB / LILA : ..................................................................
a. Muka : ...............................................................
b. Rambut : ...............................................................
c. Mata : ...............................................................
d. Hidung : ...............................................................
e. Telinga : ...............................................................
f. Mulut : ...............................................................
69
g. Leher : ...............................................................
h. Dada : ...............................................................
i. Payudara : ...............................................................
j. Ketiak : ...............................................................
k. Abdomen : ...............................................................
n. Genetalia : ...............................................................
o. Anus : ...............................................................
3. Pemeriksaan Khusus (sesuai dengan jenis Alkon yang digunakan pasien)
a. Palpasi
.........................................................................................................
.........................................................................................................
b. Inspeksi
.......................................................................................................
.......................................................................................................
c. Inspeculo
............................................................................................................
............................................................................................................
C. Data Penunjang
1. Pemeriksaan Lab : ...............................................................
2. Pemeriksaan USG : ...............................................................
III. INTERPRETASI DATA

Tanggal : ................................................. Jam : .....................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
B. Dasar
1. Dasar Subjektif : ....................................................................................
.............................................................................................................................
.............................................................................................................................
2. Dasar Objektif : .....................................................................................
.............................................................................................................................
70
.............................................................................................................................
C. Masalah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
D. Kebutuhan
....................................................................................................................................
....................................................................................................................................
VIII. DIAGNOSA POTENSIAL
...........................................................................................................................................
...........................................................................................................................................
IX. ANTISIPASI TINDAKAN SEGERA
...........................................................................................................................................
...........................................................................................................................................
X. RENCANA TINDAKAN
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
XI. IMPLEMENTASI
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
XII. EVALUASI
Tanggal : ................................................. Jam : .....................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
(...........................................) (.............................................)
NIM.
71
Mengetahui,
PEMBIMBING AKADEMIK
(........................................)
72
Lampiran. 1
FORMAT PENILAIAN PRE CONFERENCE

TEMPAT PRAKTIK : ..............................................................................................
NAMA MAHASISWA
NO ASPEK YANG DINILAI
1 2 3 4 5 6 7 8 9 10
1 Kesiapan mahasiswa dalam Pre Conference

Mengemukakan pendapat selama Pre
2
Conference
3 Ketrampilan :
a. Persiapan
b. Pelaksanaan
c. Sesudah Pelaksanaan
4 Laporan :
a. Kerapihan
b. Sistematis
5 Kehadiran
NILAI = Jumlah Nilai

8
Keterangan : *Mohon diisi dengan Nilai Absolut
Nilai Absolut Lambang Nilai Absolut Lambang
79 – 100 A 56 – 67 C
68 – 78 B < 55 D
Nama Mahasiswa : Mengetahui,
1 ................................................................. Pembimbing Lahan
2 .................................................................
3 .................................................................
4 ................................................................. (............................................)
5 .................................................................
6 .................................................................
7 .................................................................
8 .................................................................
9 .................................................................
10 .................................................................
73
FORMAT PENILAIAN POST CONFERENCE
TEMPAT PRAKTIK : ..............................................................................................
NAMA MAHASISWA
1 2 3 4 5 6 7 8 9 10
1 Kesiapan mahasiswa dalam Post Conference

Mengemukakan pendapat selama Post
2
Conference
Ketrampilan :
d. Persiapan
3
e. Pelaksanaan
f. Sesudah Pelaksanaan
Laporan :
4 c. Kerapihan
d. Sistematis
5 Kehadiran

8
Keterangan : *Mohon diisi dengan Nilai Absolut
Nilai Absolut Lambang Nilai Absolut Lambang
79 – 100 A 56 – 67 C
68 – 78 B < 55 D
2 .................................................................
3 .................................................................
4 ................................................................. (............................................)
5 .................................................................
6 .................................................................
7 .................................................................
8 .................................................................
9 .................................................................
10 .................................................................

74
PENILAIAN SIKAP MAHASISWA
TEMPAT PRAKTIK : ..............................................................................................

PEMBIMBING : ..............................................................................................
NAMA MAHASISWA
1 2 3 4 5 6 7 8 9 10
1 HUBUNGAN ANTAR MANUSIA

a. Mengadakan Pendekatan kepada klien/
keluarga/masyarakat.
b. Dapat berkomunikasi dengan semua orang
yang terkait dalam kebidanan
- Klien/keluarga/masyarakat
- Teman sejawat
- Anggota tim
PARTISIPASI DAN INISIATIF MAHASISWA DI
2
TEMPAT PRAKTIK
3 TANGGUNGJAWAB DALAM TUGAS
a. Menerima beban tugas sesuai prosedur
b. Melaksanakan tugas sesuai dengan
wewenangnya
c. Menggunakan setiap kesempatan untuk
belajar / mendapatkan pengalaman
d. Meninggalkan tempat tugas setelah
melakukan timbang terima tugas
4 KEJUJURAN
a. Melaksanakan asuhan kebidanan sesuai
dengan ketentuan yang berlkau
b. Membuat laporan sesuai data yang ada
c. Menandatangani daftar hadir sesuai
kehadiran
d. Mengakui kesalahan yang telah dilakukan /
tidak melemparkan kesalahan kepada
orang
5 KEDISIPLINAN
a. Datang tepat waktu
b. Mentaati tata tertib yang berlaku di tempat
praktek dan akademi
NAMA MAHASISWA
1 2 3 4 5 6 7 8 9 10
6 SOPAN SANTUN
Menghargai orang lain sebagai makhluk bio-
psiko-sosisl-spiritual terhadap :
- Klien/keluarga-masyarakat
75
- Teman sejawat
- Anggota tim
7 KERJASAMA
8 PENAMPILAN DIRI
Pakaian bersih dan rapi, cekatan, sabar dan

tidak ragu-ragu.
9 KETELITIAN
a. Dalam melaksanakan asuhan
b. Dalam penyusunan laporan
10 KEMATANGAN PROFESIONAL
a. Dalam melaksanakan asuhan bertindak
tenang
b. Merahasiakan dan menghindari
pembicaraan yg tidak perlu tentang
klien/klrg/masyarakat
20
Keterangan :
Nilai Absolut Lambang
79 – 100 A
68 – 78 B
56 – 67 C
< 55 D
*Mohon diisi dengan Nilai Absolut
2 .................................................................
3 .................................................................
4 ................................................................. (............................................)
5 .................................................................
6 .................................................................
7 .................................................................
8 .................................................................
9 .................................................................
10 .................................................................
76
JURNAL BIMBINGAN LAHAN
NO HARI MATERI BIMBINGAN FOLLOW UP/ PARAF

TANGGAL SARAN PEMBIMBING
77
DAFTAR HADIR MAHASISWA PRAKTEK KLINIK KEBIDANAN
AKADEMI KEBIDANAN AKBID YAPPI SRAGEN
Tempat Praktek : ...........................................................................

Tanggal Praktek : ...........................................................................
NO NIM NAMA TGL/JAM KET
Catatan : Pembimbing Lahan
…………………………………………………………………..
78

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DAFTAR PENCAPAIAN TARGET KOMULATIF PRAKTIK KLINIK KEBIDANAN

AKADEMI KEBIDANAN YAPPI SRAGEN

PKK PKK PKK PKK JUMLAH

ASUHAN KEBIDANAN IBU HAMIL

2. Alasan Datang/Keluhan : ................................................................................

c. Riwayat Kehamilan Sekarang

11) Penyuluhan yang pernah didapat :..............................................

6) Diabetes Militus : ........................................................

9) Cacat Fisik/Psikologis : ........................................................

10) Rawat Inap/Operasi : ........................................................

c. Riwayat Kesehatan Keluarga

6) Diabetes Militus : ........................................................

9) Cacat Fisik/Psikologis : ........................................................

10) Gemeli : ........................................................

d. Riwayat Penyakit Keturunan : ........................................................

5. Data Kebiasaan Sehari-hari

7. Pengetahuan Ibu tentang kehamilan : .................................................

II. INTERPRETASI DATA

2. Dasar Objektif : .........................................................................................

III. DIAGNOSA POTENSIAL

IV. ANTISIPASI TINDAKAN SEGERA

PEMBIMBING LAHAN YANG MEMBUAT LAPORAN

ASUHAN KEBIDANAN IBU BERSALIN

Tanggal Masuk : .......................................... Jam : ............................

2) Umur : ........................................ .................................

3) Pendidikan : ........................................ .................................

4) Pekerjaan : ........................................ .................................

2. Keluhan Utama pada Waktu Datang : ..................................................................

3. Tanda – Tanda Persalinan

a. Kontraksi sejak tanggal : ............................ Jam .....................................

3) Lokasi Nyeri : .................................

b. Pengeluaran per Vaginam :

2) Air Ketuban : ............................ Tanggal/Jam...........................

4) Banyak Darah : ................................................................................

9) Flour Albus : ................................................................................

b. Riwayat Kehamilan, Persalinan dan Nifas yang Lalu

6) ANC Teratur / Tidak : ........... kali (TM I : x, ; II: x ; III: )

c) TT III : tanggal ........................................

10) Obat-obatan yang dikonsumsi :

11) Penyuluhan yang pernah didapat :

12) Kebiasaan Negatif Ibu Selama Hamil

2) Umur Istri : tahun

3) Umur Suami : tahun

4) Lama pernikahan : tahun

a. Data Kesehatan Sekarang

4) Tubercolusis : tidak ada

5) Ginjal : tidak ada

6) Diabetes Militus : tidak ada

7) Malaria : tidak ada

8) HIV/AIDS : tidak ada

9) Cacat Fisik/Psikologis : tidak ada

b. Riwayat Kesehatan Dahulu

1) Jantung : tidak ada

2) Hipertensi : tidak ada

3) Asma : tidak ada

4) Tubercolusis : tidak ada

6) Diabetes Militus : tidak ada

7) Malaria : tidak ada

8) HIV/AIDS : tidak ada

9) Cacat Fisik/Psikologis : tidak ada

10) Rawat Inap/Operasi : tidak ada

c. Riwayat Kesehatan Keluarga

1) Jantung : tidak ada