contoh format askeb kehamilan

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No. Register                                                    :  …………………………....................................

Masuk RS/PKM/BPM Tanggal/Pukul            : ………………………………….......………......

Dirawat di ruang                                             : .............................................................................

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

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2.         Keluhan utama

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3.         Riwayat menstruasi

Menarche      : .................................             Siklus              : ........................................

Lama             : .................................             Teratur             : ........................................

Sifat darah    : .................................             Keluhan           : ........................................

4.         Riwayat perkawinan

Status perkawinan    : .....................             Menikah ke     : ..................................

Lama                         : .....................             Usia menikah pertama kali      : ..........

5.         Riwayat obstetrik :G.... P....A....Ah....

Hamil ke	Persalinan							Nifas
	Tanggal	Umur kehamilan	Jenis persalinan	Penolong	Komplikasi	JK	BB lahir	Laktasi	Komplikasi

6.         Riwayat kontrasepsi yang digunakan

No	Jenis kontrasepsi	Pasang				Lepas
		Tanggal	oleh	tempat	keluhan	tanggal	oleh	Tempat	Alasan

7.         Riwayat Kehamilan Sekarang

a.  HPM : ..........................                                                  

b.  ANC pertama umur kehamilan    : .......... minggu

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 : ............kali                       

TT 1 : tanggal...............................

TT 2 : tanggal...............................

TT 3 : tanggal...............................

TT 4 : tanggal...............................

TT 5 : tanggal...............................

e.  Pergerakan janin selama 24 jam(dalam sehari)

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8.         Riwayat kesehatan

a.    Penyakit yang pernah/sedang diderita (menular, menurun dan menahun)

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b.    Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan menahun)

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c.    Riwayat keturunan kembar

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d.   Riwayat operasi

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e.    Riwayat alergi obat

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9.         Pola pemenuhan kebutuhan

Sebelum hamil                                                          Saat hamil

a.    Nutrisi

Makan                                                                 

Frekuensi              : ........ x/hari                            ........... x/hari

Jenis                     : ..............................                ................................

Porsi                     : ..............................                ................................

Pantangan                        : ..............................                ................................

Keluhan                : ..............................                ................................

Minum

Frekuensi              : ........ x/hari                            ........... x/hari

Jenis                     : ..............................                ................................

Porsi                     : ..............................                ................................

Pantangan                        : ..............................                ................................

Keluhan                : ..............................                ................................

b.    Eliminasi

BAB                                                                    

Frekuensi              : ........ x/hari                            ........... x/hari

Warna                   : ..............................                ...............................

Konsistensi           : ..............................                ...............................

Keluhan                : ..............................                ...............................

BAK                                                                   

Frekuensi              : ........ x/hari                            ........... x/hari

Warna                   : ..............................                ...............................

Konsistensi           : ..............................                ...............................

Keluhan                : ..............................                ...............................

c.    Istirahat

Tidur siang                                                          

Lama                    : ........ x/menit                         ........... x/menit           

Keluhan                : ................................              ................................

Tidur malam                    

Lama                    : ........ x/menit                         ........... x/menit           

Keluhan                : ................................              ................................

d.   Personal Hygiene

Mandi                   : ...... x/hari                              ...... x/hari                               

Ganti pakaian       : ...... x/hari                              ...... x/hari

Gosok gigi            : ...... x/hari                              ...... x/hari                               

Keramas               : ...... x/minggu                        ...... x/minggu

e.    Pola seksualitas

Frekuensi              : ...... x/minggu                        ...... x/minggu

Keluhan                : ................................              ................................

                       

f.     Pola aktivitas (terkait kegiatan fisik, olah raga)

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10.     Kebiasaan yang mengganggu kesehatan (merokok, minum jamu, minuman beralkohol)

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11.     Data psikososial, spiritual dan ekonomi (penerimaan ibu/suami/keluarga terhadap kelahiran, dukungan keluarga, hubungan dengan suami/keluarga/tetangga, perawatan bayi, kegiatan ibadah, kegiatan sosial, keadaan ekonomi keluarga

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12.     Pengetahuan ibu (tentang kehamilan, persalinan, nifas)

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13.     Lingkungan yang berpengaruh (sekitar rumah dan hewan peliharaan)

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C.       Data Objektif

1.         Pemeriksaan umum

Keadaan umum         : .......................................................................          

Kesadaran                 : .......................................................................

Status emosional       : .......................................................................

Tanda vital                :

Tekanan darah          : .............mmHg          Nadi    : ...........x/menit

Pernafasan                : ............x/menit          Suhu    : ...........x/menit

BB                            : ............kg                  TB       : ...........cm

          

2.         Pemeriksaan Fisik

Kepala           : .................................................................................................................

Wajah            : .................................................................................................................

Mata              : .................................................................................................................

Hidung          : .................................................................................................................

Mulut            : .................................................................................................................

Telinga          : .................................................................................................................

Leher             : .................................................................................................................

Dada             : .................................................................................................................

Payudara       : .................................................................................................................

Abdomen      : .................................................................................................................

Palpasi

Leopold I      : .................................................................................................................

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Leopold II    : .................................................................................................................

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Leopold III   : .................................................................................................................

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Leopold IV   : .................................................................................................................

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Osborn test   : .................................................................................................................

Pemeriksaan Mc. Donald

TFU              : ...........cm                  TBJ      :..................................................................

Auskultasi

Djj                 : ...........x/menit

Ekstremitas Atas       : .....................................................................................................

Ekstremitas Bawah   : .....................................................................................................

Genetalia luar            : .....................................................................................................

Pemeriksaan panggul: ....................................................................................................

       (bila perlu)                   .....................................................................................................

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3.         Pemeriksaan penunjang        Tgl       : ....................... Pukul : .........WIB

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4.         Data penunjang

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II.           INTERPRETASI DATA

A.    Diagnosa kebidanan

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Data Dasar:

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B.     Masalah

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Data Dasar:

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III.        IDENTIFIKASI DAN ANTISIPASI DIAGNOSA POTENSIAL

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IV.        TINDAKAN SEGERA

A.       Mandiri

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B.        Kolaborasi

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C.        Merujuk

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

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VI.        PELAKSANAAN        Tanggal: ..........................................   Pukul : ................WIB

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VII.     EVALUASI                  Tanggal : ........................................... Pukul : .......... .....WIB

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