Politeknik Kesehatan Kementerian Kesehatan Jakarta 1 Jurusan Kebidanan Nama Mahasiswa NIM Tingkat : ...................................... : ...................................... : ...................................... FORMAT KEBIDANAN IBU HAMIL I. Data Subyektif Tanggal...................................... Pukul............................... Tempat...................................... A. Biodata Nama Klien :................................... Nama Suami :.................................. Umur :................................... Umur :.................................. Agama :................................... Agama :.................................. Suku/Bangsa :................................... Suku/Bangsa :.................................. Pendidikan :................................... Pendidikan :.................................. Pekerjaan :................................... Pekerjaan :.................................. Alamat/Tlp :................................................................................................................. ................................................................................................................................................. Golongan Darah Klien :.................................................................................................... Golongan Darah Suami :.................................................................................................... Keluarga yang bisa dihubungi :....................................................................................... B. Alasan Kunjungan Pertama/Ulang/dengan keluhan Gravida : Usia Kehamilan : Keluhan Utama : ....................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... C. Riwayat Menstruasi - Menarche : Umur :.................................................................................................. - Menstruasi : Siklus :.................................................................................................. Lama :.................................................................................................. Banyak :.................................................................................................. Teratur/Tidak :.................................................................................................. Disminore :.................................................................................................. 1 Politeknik Kesehatan Kementerian Kesehatan Jakarta 1 Jurusan Kebidanan Konsistensi - - :.................................................................................................. HPHT : Tanggal Lama Banyak Konsistensi Taksiran Persalinan D. Hasil Tes Kehamilan Tanggal Tes :.................................................................. :.................................................................. :.................................................................. :.................................................................. :.................................................................. :.................................................................. :.................................................................. E. Pergerakan Fetus Dirasakan pertama kali usia Pergerakan Fetus dalam 24 jam terakhir :................................................... :................................................... F. Kebiasaan Sehari-hari 1. Pola Makan :............................................................................................................... Porsi :............................................................................................................... Menu makanan sehari-hari :................................................................................................... ................................................................................................................................................ Perubahan makan yang dialami (termasuk ngidam, nafsu makan, dll) ................................................................................................................................................ ................................................................................................................................................ 2. Pola Eliminasi BAK :............................................................................................................... BAB :............................................................................................................... 3. Aktivitas sehari-hari :................................................................. Dibantu/ Tidak 4. Pola istirahat dan tidur Tidur siang :..........................jam Tidur malam :..........................jam G. Skrining TT TT1 : Pernah/Tidak Kapan : ............................................. TT2 : Pernah/Tidak Kapan : ............................................. TT3 : Pernah/Tidak Kapan : ............................................. TT4 : Pernah/Tidak Kapan : ............................................. H. Riwayat KB I. 1. Kontrasepsi yang pernah digunakan...................................................................................... 2. Efek samping......................................................................................................................... 3. Lama penggunaan.................................................................................................................. 4. Kontrasepsi terakhir............................................................................................................... 5. Alasan berhenti...................................................................................................................... Riwayat Kehamilan sekarang ANC dimana ANC oleh :.............................................................................................................. :.............................................................................................................. 2 Politeknik Kesehatan Kementerian Kesehatan Jakarta 1 Jurusan Kebidanan Frekuensi ANC :............................... Teratur/Tidak Konsumsi FE : Ada / Tidak Jumlah konsumsi Fe :........................ USG : Pernah/ tidak Hasil USG :.............................................................................................................. Masalah/Keluhan : Trimester I.................................................................................................................................... Trimester II................................................................................................................................... Trimester III.................................................................................................................................. J. Riwayat Kehamilan yang lalu Masalah/Keluhan : Trimester I.................................................................................................................................... Trimester II................................................................................................................................... Trimester III.................................................................................................................................. K. Riwayat persalinan yang lalu No Tgl/Thn Tempat Usia Jenis Tempat/ Partus Partus Kehamilan Partus Penolong Penyulit JK BB PB (gram) (cm) Ket- L. Riwayat nifas yang lalu ASI Komplikasi : Colostrum keluar / tidak ASI Eksklusif ya / tidak Berapa lama disusui : Anak ke-1.................................... Anak ke-2.................................... Anak ke-3.................................... dst :........................................................................................................................... Luka perineum :........................................................................................................................... M. Riwayat Ginekologi 1. Infeksi pada vagina.......................................................................................................... 2. Paps smear/IVA test......................................................................................................... 3. Pembedahan di daerah kemaluan................................................................................... 3 Politeknik Kesehatan Kementerian Kesehatan Jakarta 1 Jurusan Kebidanan 4. Pembedahan di daerah payudara.................................................................................... 5. Infertilitas......................................................................................................................... N. Riwayat Kesehatan 1. Riwayat penyakit yang pernah/sedang diderita ......................................................................................................................................... 2. Obat rutin yang dikonsumsi ......................................................................................................................................... 3. Riwayat kecelakaan/pendarahan/trauma ......................................................................................................................................... 4. Riwayat penyakit jiwa ......................................................................................................................................... 5. Riwayat transfusi ......................................................................................................................................... 6. Riwayat alergi obat/makanan .......................................................................................................................................... 7. Riwayat keluarga Riwayat keturunan kembar : ........................................................... Riwayat penyakit keluarga/keturunan :............................................................ 8. Perilaku yang merugikan kesehatan Penggunaan alkohol : ..................................................................................... Obat-obatan : ..................................................................................... Merokok, makan sirih : ..................................................................................... Iritasi vagina/ ganti pakaian dalam : ........................ /......................................... O. Riwayat Sosial 1. Apakah kehamilan ini direncanakan/ diinginkan?................................................................... 2. Jenis kelamin yang diharapkan................................................................................................ 3. Status perkawinan................................................................................................................... Jumlah............................... kali Lama perkawinan :.............................. Usia pertama menikah :............................................ 4. Hubungan dengan suami........................................................................................................ 5. Pengambilan keputusan dalam keluarga ............................................................................... 6. Rencana tempat melahirakan................................................................................................. 7. Rencana pemberian makan bayi............................................................................................. 8. Hubungan dengan keluarga/ibu dan mertua.......................................................................... 9. Hubungan dengan tetangga ................................................................................................... 10. Susunan keluarga yang tinggal serumah No Umur (tahun) Jenis Kelamin Hub. Keluarga Pendidikan Pekerjaan Ket 4 Politeknik Kesehatan Kementerian Kesehatan Jakarta 1 Jurusan Kebidanan 11. Kepercayaan yang mempengaruhi ibu hamil .......................................................................................................................................................... .......................................................................................................................................................... 12. Kekerasan dalam rumah tangga .......................................................................................................................................................... II. Data Obyektif A. Pemeriksaan Fisik 1. Keadaan Umum..................................... 2. Tanda – Tanda Vital Tekanan darah :.................. mmHg Suhu tubuh :...................OC 3. Tinggi Badan :...................cm 4. 5. 6. 7. Kesadaran :..................................... Denyut nadi :.............. x/menit Pernafasan :...............x/menit BB :................Kg Sebelum hamil :................Kg Kenaikan BB selama hamil :....... kg LILA :.........................cm Kepala : Rambut :…………………………………………………………............................ Muka :........................................................................................ Mata :........................................................................................ Mulut/gigi :........................................................................................ THT :........................................................................................ Leher : Kel.Tyroid :........................................................................................ Vena Jugolaris :........................................................................................ Kel. Getah bening :......................................................................................... Dada dan axila Dada : Mammae : Membesar :.............................. Simetris:.......................................... Benjolan/tumor ........................................................................................................ Areola........................................................................................................................ Papilla mammae :............................................ Pengeluaran :................................... Striae......................................................................................................................... Axilla :................................................................................................................................... 8. Abdomen Inspeksi Pembesaran : ................................................................................................. Memanjang/melintang : ................................................................................................ Linea alba/nigra ....................................... Striae albicans /livide.................................... Bekas luka operasi / SC : ................................................................................................. Gerakan Janin : ................................................................................................. 5 Politeknik Kesehatan Kementerian Kesehatan Jakarta 1 Jurusan Kebidanan Palpasi TFU Leopold I Leopold II Leopold III Leopold IV : ...........................cm (Mc. Donald) : TFU.................................................................................................... ........................................................................................................... : (kanan).............................................................................................. (kiri)................................................................................................... : .......................................................................................................... :........................................................................................................... Kontraksi :........................................................................................................... Pergerakan Janin :............................................................................................................ TBJ :........................................................................................................... Auskultasi Frekuensi :............................./menit, teratur/ tidak, intensitas...................................... Punctum maksimum................... tempat ........................................................................ 9. Punggung dan pinggang Posisi tulang belakang Nyeri pinggang : ............................................................................................. : ............................................................................................. 10. Ekstremitas atas dan bawah Atas Bawah Refleks patela : ............................................................................................. : ............................................................................................. : ............................................................................................. 11. Pemeriksaan anogenital Warna vulva vagina Luka parut Varises Pemeriksaan kel. Bartholin Pengeluaran pervaginam Kelainan Kebersihan Haemoroid pada anus : ............................................ : ............................................ : ............................................ : ............................................ : ............................................ : ............................................ : ............................................ : ............................................ B. Pemeriksaan Penunjang Darah : Hb........................gram% Golongan Darah :......................................... Urine : Protein :......................... Reduksi :...................................................... 6 Politeknik Kesehatan Kementerian Kesehatan Jakarta 1 Jurusan Kebidanan Pemeriksaan penunjang lain :.................................................................................................... ................................................................................................................................................... III. Analisa ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ Penatalaksanaan ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... Mengetahui : Pembimbing Akademik (...........................................) CI / Pembimbing Lahan (........................................) 7