Jumat, 03 Mei 2013

Format Askeb Ibu Bersalin



 .........................................................................................................................................................................................................................................................................................................................................................................................................................................................
No. Register                                                    : .........................................................................
Tanggal RS/PKM/BPM Tanggal /Pukul         : .........................................................................
Tempat                                                            : .........................................................................

I.         PENGKAJIAN DATA   Tanggal / Pukul:................................... Oleh:....................... ..
A.   Biodata
Ibu                                                  Suami
1.      Nama               :............................................               ...................................................
2.      Umur               :............................................               ...................................................
3.      Agama             : ...........................................               ...................................................
4.      Suku/Bangsa   :............................................               ...................................................
5.      Pendidikan      :............................................               ...................................................
6.      Pekerjaan         : ...........................................               ...................................................
7.      Alamat                        : ...........................................               ...................................................
B. Data Subjektif
1.    Alasan datang / dirawat
..............................................................................................................................................................................................................................................................................

2.    Keluhan Utama
..............................................................................................................................................................................................................................................................................

3.    Riwayat Menstruasi
Menarche         :........................................                   Siklus              :..........................
Lama               :…....................................                   Teratur             :..........................
Sifat Darah      :........................................                   Keluhan           :..........................

4.      Riwayat Perkawinan
Status pernikahan        :...........................                    Menikah ke     :.........................
Lama                           :...........................                    Usia menikah pertama kali :......





5.         Riwayat Obstetrik       : P...A...Ah....
Hamil



Persalinan



Nifas
Ke
Tanggal
Umur kehamilan
Jenis Persalinan
Penolong
Komplikasi
JK
BB Lahir
Laktasi
Komplikasi



















































6.        Riwayat kontrasepsi yang digunakan
No
Jenis

Pasang



Lepas



Kontrasepsi
Tgl
Oleh
Tempat
Keluhan
Tgl
Oleh
Tempat
Keluhan

Ibu mengatakan belum pernah menggunakan alat kontrasepsi









7.         Riwayat Kehamilan sekarang
a. HPHT                                              :................................   HPL    :..........................
b. ANC pertama umur kehamilan       : ...............................
c. Kunjungan ANC
   Trimester I   
   Frekuensi      :..............kali
   Keluhan        :..............        
   Komplikasi   :..............
   Terapi           :..............
   Trimester II
   Frekuensi      :..............kali
   Keluhan        :..............
   Komplikasi   :..............
   Terapi           :..............
   Trimester III
   Frekuensi      :..............kali
   Keluhan        :..............
   Komplikasi   :..............
   Terapi           :..............



d. Imunisasi TT
TT 1 :...................
TT 2 :...................
TT 3 :...................
TT 4 :...................
e. Pergerakan janin selama 24 jam (dalam sehari)
  .....................................................................................................................................................................................................................................................
8.      Riwayat Kesehatan
a.       Penyakit yang pernah/sedang diderita (menular, menurun, dan menahun)
............................................................................................................................      ...........................................................................................................................
b. Penyakit yang pernah/sedang diderita keluarga (menular,menurun, dan      menahun)
...............................................................................................................................................................................................................................................
c. Riwayat keturunan kembar
...................................................................................................................................................................................................................................................
d. Riwayat Operasi
...........................................................................................................................................................................................................................................
e.   Riwayat Alergi Obat
.........................................................................................................................................................................................................................................

9.      Pola Pemenuhan Kebutuhan sehari-hari
Sebelum Hamil                                                       Setelah Hamil
a.       Pola Nutrisi
-          Makan
Frekuensi    :.................      x/hari               ...........................
Porsi           :.................                              ...........................
Jenis            :.................                              ...........................
Pantangan   :.................                              ...........................
Keluhan      :.................                              ...........................

-          Minum
Frekuensi    :.................                              ...........................
Porsi           :.................                              ...........................
Jenis            :.................                              ...........................
Pantangan   :.................                              ...........................        
Keluhan      :.................                              ...........................        
b.       Eliminasi
-          BAB
Frekuensi    : .................                             ............................       
Konsistensi : .................                             ............................
Warna         : .................                             ............................       
Keluhan      : .................                             ............................       

BAK
Frekuensi    : .................                             ............................       
Konsistensi : .................                             ............................                   
Warna         : .................                             ............................
Keluhan      : .................                             ............................       
c.        Istirahat
Tidur siang                                                 Tidur malam
Lama          : .................                             ............................
Keluhan      : .................                             ............................
    d.Personal hygiene
Mandi               : .................                             ............................       
Ganti pakaian   : .................                             ............................       
Gosok gigi        : .................                             ............................       
Keramas           : .................                             ............................       
e.Pola seksualitas
Frekuensi          : .................                             ............................       
Keluhan            : .................                             ............................
     f. Pola aktifitas ( terkait kegiatan fisik, olah raga )
.....................................................................................................................................................................................................................................................................................................................................................................
10.  Kebiasaan yang mengganggu kesehatan (merokok, minum jamu, minuman beralkohol)
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
11.  Psikososiospiritual (persiapan menghadapi persalinan)
..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
12.  Pengetahuan ibu (tentang kehamilan, persalinan, dan nifas)
..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
13.  Lingkungan yang berpengaruh (sekitar rumah dan hewan peliharaan)
..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
C. DATA OBYEKTIF
1.           Pemeriksaan Umum
Keadaan Umum     :.........................................................................         
Kesadaran              :.........................................................................         
Status Emosional    :.........................................................................
Vital Sign
Tekanan Darah       :..............mmHg                     Nadi                :............x/menit
Pernafasan              : .............x/menit                    Suhu                :............ °C
Berat badan                        : .............kg                            Tinggi badan   :............ cm
2. Pemeriksaan Fisik
Kepala        :..............................................................................................................
Wajah         :..............................................................................................................
Mata           :..............................................................................................................
Hidung       :..............................................................................................................
Mulut          :..............................................................................................................
Telinga        :..............................................................................................................
Leher          :..............................................................................................................
Dada           :..............................................................................................................
Payudara    :..............................................................................................................
Abdomen   :..............................................................................................................
           
 Palpasi Leopold
Leopold I             :..................................................................................................
Leopold II                        :..................................................................................................
Leopold III          :..................................................................................................
Leopold IV          :..................................................................................................

Supra pubic             :..................................................................................................
Osborn test             :..................................................................................................

TFU menurut Mc. Donald 
TFU:...................cm                                               TBJ:........................................
Auskultasi DJJ
DJJ:.....................x/menit

Ekstremitas atas          :..................................................................................................
Ekstremitas bawah      :..................................................................................................
Genetalia luar              :..................................................................................................
Pemeriksaan Dalam     :..................................................................................................
...................................................................................................................................................................................................................................................................................................

3. Pemeriksaan Penunjang           Tgl       :.......................... Pukul:..............WIB
...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4. Data Penunjang
...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
II. INTERPRETASI DATA
A.    Diagnosa Kebidanan
............................................................................................................................................................................................................................................................................
Data dasar :
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
B.     Masalah
............................................................................................................................................................................................................................................................................

Data dasar :
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

III. IDENTIFIKASI DIAGNOSA/MASALAH POTENSIAL
.....................................................................................................................................................................................................................................................................................................................................................................................................................
IV. TINDAKAN SEGERA
A.    Mandiri
............................................................................................................................................................................................................................................................................
B.     Kolaborasi
............................................................................................................................................................................................................................................................................
C.     Merujuk
............................................................................................................................................................................................................................................................................

V. PERENCANAAN                       Tanggal :..............................   Pukul : ..................WIB
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................




VI. PELAKSANAAN                     Tanggal :..............................   Pukul : ..................WIB
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
VII.  EVALUASI                              Tanggal :..............................   Pukul : ..................WIB
......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................








PERKEMBANGAN
KALA
         I.            DATA SUBYEKTIF,           Tanggal :...................., jam :............................    WIB
......................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
II. DATA OBYEKTIF,                 Tanggal :................... , jam :............................    WIB
......................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

III. ASESSMENT
1. Diagnosa kebidanan
......................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2. Diagnosa masalah
......................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

IV. PENATALAKSANAAN,      Tanggal :................... , jam :............................    WIB
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................















LEMBAR OBSERVASI
No. Reg :...........................Nama pasien :....................... Umur:.......th      Nama suami:..........
G..P..A..Ah  Alamat : ..............................................................Masuk tgl/ jam :      /       WIB
Ketuban pecah sejak jam :...............WIB   Mules sejak jam :............WIB

TGL
JAM
DJJ
HIS
NADI
(x menit)
SUHU (ºC)
LAIN-LAIN
(TD,Ketuban,PD,Px Penunjang )
      Frek.
(x10 menit )
Durasi
( detik )
Kekuatan

























































































































































































































































































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